Impact of COVID-19 on household incomes and access to SRHR services by young people by Reach A Hand, Uganda (RAHU)

HEALTH ECONOMIST CONSULTANCY

FINAL ASSESSMENT REPORT

Submitted to Reach A Hand Uganda (RAHU) Plot 7502, Block 244 Heritage Village Kansanga, Gabba Road

By Polycarp Musinguzi Email: mpolycap@gmail.com Phone: +256-(0) 774922180

June 2021

List of Abbreviations and Acronyms AIDS

Acquired Immunodeficiency Syndrome

CBO

Community Based Organisation

CPR

Contraceptive Prevalence Rate

DHE

District Health Educator

DHO

District Health Officer

FGD

Focus Group Discussion

Family Planning

FPCIP

Family Planning Costed Implementation Plan

GoU

Government of Uganda

HIV

Human Immunodeficiency Virus

HSDP

Health Sector Development Plan

HSSP

Health Sector Strategic Plan

ICT

Information and Communication Technology

IEC

Information Education and Communication

KII

Key Informant Interview

MOH

Ministry of Health

NGO

Nongovernmental Organisation

PLHIV

People Living with HIV

PWD

People with Disabilities

RAHU

Reach A Hand Uganda

RDC

Resident District Commissioner

SOPs

Standard Operating Procedures

SRH

Sexual and Reproductive Health

SRHR

Sexual and Reproductive Health and Rights

STIs

Sexually Transmitted Infections

UDHS

Uganda Demographic and Health Survey

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Contents List of Abbreviations and Acronyms

List of Tables

List of Figures

Map of Mayuge District

vii

EXECUTIVE SUMMARY

viii

1.0

INTRODUCTION AND BACKGROUND

1.1

Introduction

1.2

Background and Context

1.3

Impact Study of the COVID- 19 response on access to SRHR in Mayuge

1.4.1 Objectives and research questions

APPROACH AND METHODOLOGY

2.0 2.1

Study design

2.2

Sampling design and techniques

2.2.1 Selection of the enumeration areas 2.2.2 Selection of the households 2.2.3 Selection of the actual respondents

2.3

Methods and tools of data collection

2.3.1 2.3.2 2.3.3 2.3.4 2.3.5 2.3.6 2.3.7

2.4

Household Survey Focus Group Discussions Key Informant Interviews Desk Review / Secondary Data Case Study Documentation Review of Health Facility Records Health Facility/Service Point Assessment

Methods and tools of data analysis

2.4.1 Processing and Analysis of Quantitative Data 2.4.2 Processing and Analysis of Qualitative Data

5 6 6

6 6 7 7 8 8 8 8

9 9 9

2.5

Data synthesis, interpretation, and reporting

2.6

Quality assurance and backstopping

2.7

Compliance with ethical guidelines

2.8

Adherence to Covid-19 SOPs

3.0

PRESENTATION AND DISCUSSION OF RESULTS Page iii of 118

3.1

Respondents’ demographic characteristics

3.2

Availability, Access to and Utilization of SRHR Services by Young People 14

3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.2.7

Availability of sexual and reproductive health services Access to and utilization of SRH services during the lockdown Access to SRH for vulnerable populations groups Sexual behaviour, access, and utilization of contraceptives Exposure to SRHR Information and communication Availability and utilization of SRH youth-friendly services Care-giver –Young persons’ engagement on SRHR services

14 16 22 22 27 29 31

3.3 Role of district and community leaders in promoting SRHR during the pandemic 35 3.4

Impact of COVID-19 response measures on household livelihood

3.4.1 3.4.2 3.4.3 3.4.4 3.4.5 3.4.6 3.4.7

4.0

Household’s livelihood dynamics Impact of COVID-19 on household income and expenditure Impact of COVID-19 on household food security Impact of COVID-19 on jobs and employment Effect of COVID-19 on domestic social relations and SGBV Impact on health spending and utilization of SRH services Household COVID-19 coping mechanisms

Conclusions and Recommendations

39 39 39 43 47 49 53 56

4.1

Conclusions

4.2

Recommendations

ANNEXES

Annex 1: Questionnaire for the Young People (10-24 Years) 63 Annex 2: Questionnaire for Caregivers of Young People (10-24 Years) 74 Annex 3: FGD Guide for Young People (Male and Female) Aged 10-24 years 85 Annex 4: FGD Guide for Caregivers of Young People (Male and Female) 87 Annex 5: Interview Guide for District/Sub-county Health Officials and Political Leaders 89 Annex 6: Interview Guide for Peer Educators 90 Annex 7: Interview Guide for Health Workers / In charges of Health Facilities 92 Annex 8: Case Study Documentation Guide 93 Annex 9: Service Point Records Review Form 94 Annex 10: Facility Assessment Questionnaire 96 Annex 11: List of Key Informants Interviewed 102 Annex 11: Letter of introduction endorsed by the District Authorities. 103

References

105

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List of Tables Table 1: Administrative and Health Units in the study sub-counties. ...................................... 4 Table 2: Study Parishes and Villages. ...................................................................................... 5 Table 3: Distribution of FGDs per category. ............................................................................ 7 Table 4: Demographic characteristics of caregivers .............................................................. 11 Table 5: Demographic characteristics of young people......................................................... 12 Table 6: Need for SRH services by age. ................................................................................. 16 Table 7: Sexual behaviour and use of contraceptives. .......................................................... 23 Table 8: Exposure to SRH information during the lockdown. ................................................ 27 Table 9: Availability and utilization of youth-friendly RSH services. ...................................... 30 Table 10: Caregiver perceptions on young people’s access to SRH services. ........................ 31 Table 11: Discussion of SRH issues with young people during the lockdown. ....................... 33 Table 12: Young people’s source of information of SRH during the lockdown...................... 35 Table 13: Chi-square results on the number of meals per day by sub-county ...................... 45 Table 14: Chi-square result on food security by the source of food ...................................... 46

List of Figures Figure 1: The Convergent Parallel / Concurrent Triangulation Design (Creswell 2009) ........... 4 Figure 2: Forms of paid work engaged in by young people. .................................................. 13 Figure 3: SRH services availability during the lockdown. ....................................................... 14 Figure 4: SRH services needed during the lockdown. ............................................................ 16 Figure 5: Need for SRH services in intervention and control area. ........................................ 17 Figure 6: Young people who sought and obtained SRH services. .......................................... 18 Figure 7: SRH services sought and obtained during the lockdown. ....................................... 19 Figure 8: Reasons for not seeking SRH services..................................................................... 20 Figure 9: Reasons for not obtaining the services sought. ...................................................... 21 Figure 10: Engagement in sex and use of contraceptives during the past 12 months........... 23 Figure 11: Contraceptive method used during last 12 months. ............................................ 24 Figure 12: Source of contraceptive during last 12 months. ................................................... 25 Figure 13: Reasons for not using contraceptives during the last 12 months. ........................ 26 Figure 14: Reported pregnancies during the past 12 months. .............................................. 26 Figure 15: Source of SRH information during the last 12 months. ........................................ 28 Figure 16: Channel through which SRH information was received........................................ 28 Figure 17: Content of SRH information received by young people. ...................................... 29 Figure 18: Services obtained by young people during the lockdown. ................................... 30 Figure 19: Subject of SRH discussion with young people. ..................................................... 34 Figure 20: Reasons for not discussing SRH with young people.............................................. 34 Figure 21: Community leaders’ support towards SRH of young people. ............................... 36 Figure 22: Major sources of income for the household ........................................................ 39 Figure 23: Estimated average monthly income. .................................................................... 40 Page v of 118

Figure 24: Estimated average monthly expenditure. ............................................................ 40 Figure 25: Estimated monthly average income by sub-county. ............................................ 41 Figure 26: Estimated monthly average expenditure by sub-county. ..................................... 41 Figure 27: Change in household income during the lockdown.............................................. 42 Figure 28: Change in household expenditure during the lockdown. ..................................... 43 Figure 29: Number of meals had a day by adults and children. ............................................ 44 Figure 30: Number of meals consumed a day by sub-county................................................ 44 Figure 31: Household food security situation during COVID 19 Lockdown. .......................... 45 Figure 32: Household food security by the source of food.................................................... 46 Figure 33: Effects of the Lockdown on household food security indicators. ......................... 47 Figure 34: COVID-19 effect on personal working hours. ....................................................... 48 Figure 35: Effect of COVID-19 on working hours by the main source of income. .................. 49 Figure 36: Cases of domestic violence in Mayuge between Jan 2020 and March 2021. ....... 50 Figure 37: Prevalence of Domestic Violence during the COVID-19 Lockdown. ..................... 50 Figure 38: Caregiver perceptions on the impact of COVID-19 on SGBV. ............................... 51 Figure 39: Perceptions of young people on the effect of COVID-19 on GBV. ........................ 51 Figure 40: Perceptions on the prevalence of domestic violence by sub-county.................... 52 Figure 41: Who paid for SRH services accessed by young people. ........................................ 54 Figure 42: Young people’s satisfaction with SRH services received....................................... 55 Figure 43: Households’ coping mechanism during the lockdown ......................................... 56 Figure 44: Receipt of aid during the lockdown. ..................................................................... 57 Figure 45: Source of support/assistance during the lockdown. ............................................ 57 Figure 46: Overall coping strategies adopted by households. ............................................... 58

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Map of Mayuge District

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EXECUTIVE SUMMARY Introduction This assessment was commissioned by Reach A Hand Uganda (RAHU) under the auspices of the “Strengthening Uganda’s Civil Society Advocacy Responses to the long-term health and social sector governance problems and structural weaknesses exposed by the COVID-19 Pandemic” project. The project is being implemented with nine other advocacy partners under the Open Society Initiative for Eastern Africa (OSIEA) and seeks to facilitate the realization of human rights and social justice in health for the most vulnerable people. In light of this objective, this assessment was undertaken to generate evidence on how Uganda’s national and localized response to the covid-19 pandemic has impacted young people’s access to and utilization of sexual and reproductive health and rights. The results of the study are expected to contribute evidence-informed recommendations to strengthen policy, programming and advocacy initiatives aimed at promoting greater realization of rights particularly Sexual Reproductive Health Rights (SRHR) of young people especially in times of crisis and uncertainty.

Background and Context Uganda has one of the highest youth populations in the world, with almost half (47.7%) of its 41.7 million people aged under 15. Following the imposition of the lockdown and the closure of educational institutions as one of the measures adopted by the government to contain the spread of the raging COVID-19 pandemic, young people majority of whom are of school-going age were sent home to their communities. However, there is a general lack of evidence on the impact of this unprecedented life event on young people’s lives, particularly regarding access to sexual and reproductive health and rights services and information, especially for a population that is known to engage in early sexual intercourse. This study was undertaken in the Eastern District of Mayuge in the Busoga region where HIV prevalence rates, as well as cases of teenage pregnancies and early marriage, are known to be disproportionately high.

Study design and methodology The study adopted a cross-sectional design, with a mix of qualitative and quantitative methods of data collection to enhance the validity of the findings. The study was implemented in the two Sub-counties of Mpungwe and Baitambogwe representing the intervention and Control Sites respectively; RAHU having previously implemented SRH interventions targeting young people in the former. Although 246 households were initially targeted, the study covered 267 households. Of these 145 were in Mpungwe, while 128 were in Baitambogwe, representing 53.11% and 46.89% respectively. In each household, two interviews, one with a caregiver and the other with a young person (10-24 years) were conducted using separate structured questionnaires that had been programmed using the XLS format and administered electronically using the Open Data Kit (ODK) Collect android application for mobile data collection. Page viii of 118

In addition, the study also collected quantitative data on the availability and utilization of key sexual and reproductive health services by young people before, during and after the lockdown. This was complemented by undertaking qualitative interviews through focus group discussions, key informant interviews and a desk review of grey and published literature on the impact of the COVID-19 and lockdown generally on the households of young people as well as access to and utilization of SRH. Throughout the execution of the study, the team observed the necessary ethical guidelines for undertaking research among human subjects and adhered to the Ministry of Health (MOH) guidelines and Standard Operating Procedures (SOPs) for preventing the spread of COVID-19.

Assessment Results/Findings Impact of COVID-19 on young people’s access to and utilization of SRHR services In most of the facilities assesses, the provision of most SRH services went on uninterrupted during the lockdown. This was attributed to routine supply by the district, with support from NGOs, especially regarding mobilization and sensitization. Only three services namely: testing for RTI/STIs, sex and sexuality counselling and IUDs were not available at some facilities during the lockdown, while female condoms were available but at a cost. Contraceptive methods (18.35%), HIV screening and testing (17.9%), SRH counselling and information (10.86%) as well as pregnancy testing (10.11%) were the most needed SRH services by young people during the lockdown. The least needed services were treatment for abortion (1.5%), SGBV counselling and support (1.9%) and postnatal care (3.75%). The need for these services was generally higher among the 15-19 age category. However, the need for maternity and child delivery services as well as postnatal care was highest among young people aged 20-24. On the other hand, young people between 10-14 years were more in in need of SRH counselling and information than any other service. Overall, there is a strong relationship between young people’s age and the need for SRH services, but the difference in the need for the services by sub-county was not striking. The most sought services by young people were antenatal care (93.33%), pregnancy testing (93%), and maternal and child delivery (92.31%), while the least sought were SGBV counselling, SRH counselling and information and testing for other STIs. Overall, a majority (93.6%) of young people who sought services obtained them. The ability to seek for and utilize SRH services was higher among young people in the intervention sub-county (Mpungwe) than the Control (Baitambogwe). However, the Pearson Chi-Square value of 0.044 points to a weak relationship between seeking for and utilizing services on the one hand, and the sub-county on the other. This was further confirmed by the odds ratio of 1.0 which suggests a weak association between the predictor and outcome variables. The predominant source of SRH services for young people was the public health facility, owing to the proximity of the facility and affordability. Failure to seek for and obtain the needed SRH Page ix of 118

services was attributed to a mix of supply and demand factors including provider characteristics. Specifically, limited awareness on where to seek the service was the overriding inhibitor for the young people to seek the needed SRH services. Other reasons included; transport challenges and stigma associated with some SRH services. On the other hand, unavailability of health workers, inability to afford the cost of the service and unavailability of the services were the major inhibitors to obtaining the needed services. Although the proportion of the young people who had any form of disability was much lower (3.4%), qualitative data indicated that this category experienced disproportional challenges in accessing SRH services during the lockdown. This was mainly due to limitations on transport because of the lockdown and associated ban on public transport as well as long distances to health facilities. Owing to these same challenges, young people in hard-to-reach areas such as islands were even more disadvantaged given that supply of SRH products was limited. Nevertheless, the study did not observe any systemic factors that constrained the provision of SRH services to vulnerable groups of young people at large. Sexual behaviour, access, and utilization of contraceptives Whereas the majority (83%) of the young people reported having engaged in sexual intercourse during the lockdown period, contraceptive use was reported by only 60.8%. The use of contraceptives during the lockdown was however higher (53.9%) in the intervention sub-county than in the control. Despite the slight variations in the observed results, the use of contraceptives cannot be attributed to the peculiar factors in the intervention and control sub-counties as evidenced by the P-value of 0.384. Male condoms and injectables accounting for 55.4% and 26.2% were the most common forms of contraceptives methods used by young people during the lockdown, while the least used were female condoms (1.54%), lactational amenorrhea (1.54%) and implants (3.1%). The predominant use of male condoms may be explained by the extensive availability at most health facilities and in the community at no cost. Indeed, public health facilities were the dominant source of contraceptive for young people during the lockdown. The most dominant reasons for not using contraceptives among young people were partner objection, need for children and fear of side effects. Prevalence of pregnancy among young people during the lockdown was 21%, with the Pearson Chi-Square result of 0.000 suggesting a strong relationship between contraceptive use and pregnancy/conception. Role District and community leaders in the access of SRHR services The majority (72.2%) of the caregivers interviewed did not know any role or assistance rendered by the district and other community leaders in facilitating young people’s access to sexual and reproductive health services during the lockdown. On the other hand, 10.3% and 2.2% respectively reported that local leaders were instrumental in raising awareness about SRH services and issuing movement permits. Only 7.6% of young people interviewed were Page x of 118

reported to have obtained SRH information from local leaders/politicians, 5.63% from VHTs and 2.11 from religious leaders. In addition, the district and community leaders were instrumental in eliminating various supply and demand-related factors that affect the provision of SRH services including the supply of the needed SRH products to health facilities in the district. However, local leaders are reported to have experienced challenges in supplying SRH products to facilities in hard-to-reach areas such as islands. Impact of the pandemic on the households of young people 10-24. Homegrown food was the main source of food for a majority (85.7%) of the households during the lockdown. The majority of the households could afford two or more meals per day for adults (96.6%) and children (79.1%) at the time of the study, and there were no significant variations between the intervention and control sub-counties as evidenced as a Chi-Square value of 0.88. However, 20.3% and 28.3% of the households in Baitambogwe and Mpungwe sub-counties respectively could not afford a minimum of three (3) meals a day during COVID19 lockdown between March and April 2020. On the other hand, the majority of the households in both sub-counties could afford at least three meals a day. Although weak, there was a relationship between the main source of food and food security during the lockdown, as evidenced by a Pearson Chi-Square result of 0.030. There was no relationship between food security during the lockdown and the sub-county as evidenced by the Chi-square result of 0.127. The results show that COVID-19 and the associated containment measures such as the lockdown had an adverse impact on employment. In 23% of the surveyed households, it was reported that a member lost a job, while a majority (70%) of the caregivers were reported to have experienced a decrease in working hours during the lockdown, the majority of whom were engaged in casual labour (16.7%) and business/trading (13.3%). On the other hand, the largest increases in working hours were reported among caregivers engaged in casual labour (66.6%), farming (65.7%), salaried employment (60%) and business/trading (60%). Households which experienced a decrease in income and an increase in expenditure were 89.4% and 80.22% respectively. Among all the surveyed households, 39.6% had a member who experienced emotional violence during the lockdown, while 18.3% and 5.9% had members who experienced at least one form of physical and sexual violence, respectively. On the other hand, 47.9%, 39.3% and 10.5% of young people reportedly experienced some emotional, physical, and sexual violence respectively during the lockdown. Furthermore, 61.9%, 42.5% and 58.2% of caregivers interviewed were of the view that cases of emotional violence, sexual violence and physical violence respectively had increased in the community during the lockdown. These results were corroborated by data from the police that indicated that in total 300 cases of domestic violence were reported in Mayuge between January 2020 to March 2021, with many other cases thought to not have been reported. Page xi of 118

The most dominant strategies adopted by families to deal with the challenges posed by COVID-19 and the associated lockdown were depletion of savings (75.1%), sale of livestock/poultry (48.72%) and borrowing money (41.4%). More than a quarter of households (34.43) skipped making payments on their loans. The majority (85.1%) of the surveyed households did not receive any form of aid during the lockdown. Among those that received aid/assistance, food (35%) and cash/money (23%) were the most dominant forms of support to make ends meet. Relatives and government accounting for 45.83% and 35.42% respectively were the most dominant sources of aid for families in need during the lockdown. Overall, a majority (78.4%) of the surveyed households reported having had to diversify their income sources to cope with the challenges of the lockdown, while 51.7% reduced household expenditure and 41.8% increased working hours. An overwhelming (93.59%) number of young people who sought SRH services during the lockdown ultimately accessed them. Of these, slightly more than a quarter (27.1%) paid, while the majority (72.74%) did not incur any cost to access services. Among those who paid, a majority (52.2%) were in Baitambogwe, while the rest were in Mpungwe sub-county. Among those who paid, 68% regarded the cost as high, while 28% found the cost of SRH services to be affordable. A majority (62%) of the young people who accessed and utilized services paid for themselves, while 13% were paid for by their caregivers/parents. More than half (55.7%) of the young people interviewed reported that SRH expenditure had increased since the imposition of the lockdown, while 22.2% did not observe a decrease.

Recommendations •

•

Strengthen the capacity of parents to effectively engage in sex and sexuality talks with their young people. A lot more needs to be done to change the demystify parents’ attitudes towards SRH. Information, Education and Communication about SRH for young people should emphasize the notion of age-appropriate interventions. In the same spirit, there is a need to continue sensitization aimed at progressively changing the societal wide negative attitudes, beliefs and perceptions regarding SRH in general and family planning in particular. Religious, cultural, and other opinion leaders need to be targeted and involved. Reach A Hand through their community structures such as the peer educators and in partnership with other players the SRH sector need to accelerate the SRH campaign beyond schools and other formal settings to informal community spaces where young people routinely meet and interact. Continue to lobby the government to provide adequate funding for youth-friendly corners and ensure that staff there are trained in the provision of youth-friendly SRH services. Improve the coordination between the providers of SRH services, especially information. Formation/strengthening the capacity of working groups that bring together all key stakeholders in the space of SRH promotion and service delivery.

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1.0 INTRODUCTION AND BACKGROUND 1.1

Introduction

This report presents the results of a study that was commissioned by Reach A Hand Uganda (RAHU) and undertaken by Polycarp Musinguzi an independent Sexual and Reproductive Health (SRH) Consultant. The overall purpose of the study was to examine/assess the impact of Covid 19 response on young people’s access to and utilization of Sexual and Reproductive Health and Rights (SRHR) services and information in Mayuge District in, Eastern Uganda, under the “Strengthening Uganda’s Civil Society Advocacy Responses to the long-term health and social sector governance problems and structural weaknesses exposed by COVID-19 Pandemic”. Data collection for the study was conducted in May 2021. This report is organized into five (5) major Chapters. Chapter One provides a background to the study including Uganda’s population trajectory and the case for SRH. The Chapter concludes with the study purpose and objectives. Chapter Two presents the approach and methodology used in executing the study. It covers the overall study design, the study area and population, sampling techniques, methods and tools of data collection, data management and analysis, quality control and ethical considerations. Chapter Three presents the findings of the study in line with the objectives. It is broadly organized under four sections, namely; Socio-demographic characteristics; Access to and utilization of SRH services; Role of district and community leaders in promoting access to SRH during the lockdown; Impact of COVID-19 on household income and expenditure; Impact of COVID-19 response measures on household livelihood. Chapter Four presents the conclusions and recommendations to inform future programming and policy and advocacy based on the study findings.

1.2

Background and Context

With a total fertility rate of 6.2 (UBOS and ICF International 2012), Uganda’s population growth rate of 3% is one of the highest in the world. The country has one of the highest youth populations in the world, with almost half (45.5%) of its estimated 47.1 million people aged under 15 (UNFPA 2021). More than half (52.6%) of the country’s population is below 18 (UBOS, 2020). Research also suggests that young people in Uganda become sexually active at an early age, with more than half of young women having their first sexual encounter before age 18 (UDHS, 2016). Despite the evidence of the early onset of sexual intercourse among adolescents, contraceptive use is low, with a contraceptive prevalence rate (CPR) of only 11% among young people. This contributes to unplanned/unwanted pregnancies, unsafe abortions, and related complications, resulting in disproportionately high maternal mortality and morbidity. Teenage pregnancy in Uganda is very high, as 24% of adolescents have already begun childbearing (UBOS and ICF International, 2012), and is also a major cause of school dropouts. The evidence in the regular DHS shows that adolescents and young adults are particularly at risk of unintended pregnancy. Page 1 of 118

Evidence also shows that the contraceptive prevalence rate (CPR) is lowest amongst married young people aged 15–24 years at only 11% (UBOS and MEASURE DHS/ICF International, 2012). This is a serious concern given the youthful population of the country. DHS Reports also show that 25% of teenage girls in Uganda are either pregnant or have given birth. More than half of young women have had their first sexual encounter before age 18 (NPA 2014). The limited cultural space to discuss sex and sexuality between parents/guardians and children implies that young people are often left to seek information on sexual matters on their own or to experiment with sex, and hence, engage in risky sexual behaviour with increased probability of teenage pregnancy, early marriage, and early childbearing. Lack of, or limited, access by adolescent girls to FP, including contraceptive information, education, and services, is a major factor contributing to unwanted teenage pregnancy and maternal death. Unintended pregnancies lead to high levels of unplanned births, unsafe abortions, and maternal injury and death. These unfriendly statistics place more responsibility on Government and partners to urgently scale out FP, find innovative ways to increase the method mix to widen opportunities and promote informed choice from a variety of commodities for young people with a greater focus on those considered to be more vulnerable including young people with disabilities, those from poor households, those in hard to reach areas, young people using drugs as well as young people living with HIV and AIDS among others.

1.3

Impact Study of the COVID- 19 response on access to SRHR in Mayuge

Reach A Hand Uganda (RAHU) together with a consortium of other nine advocacy partners under the Open Society Initiative for Eastern Africa (OSIEA) have been implementing the “Strengthening Uganda’s Civil Society Advocacy Responses to the long-term health and social sector governance problems and structural weaknesses exposed by COVID-19 Pandemic”. The shared purpose of this initiative was to facilitate the realization of human rights and social justice in health for the most vulnerable people. Under this project, Reach A Hand Uganda’s role was to “contribute to generating evidence at the grassroots through research and the collective feedback of its youth champions and relevant community stakeholders”. Therefore, it is against this background that this study was commissioned to generate evidence on how Uganda’s national and localized response to the covid-19 pandemic has impacted young people’s access to and utilization of sexual and reproductive health and rights. It is envisaged that the findings of this study will be used by stakeholders in the SRHR field including government and civil society actors to augment the delivery of services targeting young people in such crises. Specifically, the results of this study are intended to guide the formation of evidence-informed recommendations to strengthen policy, programming and advocacy initiatives aimed at promoting greater realization of rights particularly Sexual

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Reproductive Health Rights (SRHR) of young people especially in times of crisis and uncertainty with a focus on the most vulnerable. This is premised on the realization that there is a general lack of evidence on the impact of these covid19 response measures on sector-specific issues including young people’s access to sexual and reproductive health and rights services and information. Most of the studies have focused on the impact on the economy, the effect on the mental health of some sections of the population, the effect on family cohesion as well as the general disruption of service delivery. Other non-academic works have reported a general rise in cases of rape, early marriages, teenage pregnancies, and domestic violence during the lockdown. It is, therefore, apparent that there is a dearth of evidence on the impact of covid-19 and the associated national and local response on young people’s access to and utilization of sexual and reproductive health and rights services and information. The implication is that without access to services and information to enable young people to make an informed and responsible decisions, thus exacerbating the risk of unplanned/unwanted pregnancies, unsafe abortions, and related complications, resulting in disproportionately high maternal mortality and morbidity. 1.4.1 Objectives and research questions The overall purpose of this study was to assess the impact of Covid 19 response on young people’s access to Sexual and Reproductive Health and Rights (SRHR) services and information with a particular emphasis on vulnerable populations. Specifically, this study sought to i. Examine the effect of COVID 19 in the access of the SRHR services among young people 10-24 and vulnerable populations. ii. Identify the impact of the national response to COVID-19 on access to SRHRs for young people. iii. Establish the role of the district and community leaders in the access of SRHR services during the COVID 19 Pandemic. iv. Assess the effects of the pandemic on the households of young people 10-24. In line with the objectives outlined above, this study sought to answer the following key questions. 1. What is the percentage of the young people and vulnerable groups affected by COVID 19 in the access of SRHR services? 2. What is the percentage of households affected by COVID 19 in the access of SRHR? 3. To what extent did the district and community leaders contribute to the access of SRHR services during the COVID 19 Pandemic?

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2.0 APPROACH AND METHODOLOGY 2.1

Study design

The study adopted a mixed-methods approach combining quantitative and qualitative methods. Specifically, a Convergent Parallel / Concurrent Triangulation design where both qualitative and quantitative methods data are collected simultaneously but analyzed separately and the results compared to enhance the validity of the study findings was used as illustrated below.

Figure 1: The Convergent Parallel / Concurrent Triangulation Design (Creswell 2009) The choice of a mixed-methods approach was based on the need to facilitate an all-around understanding of the impact of COVID-19 on young people and their households, given that the two methods are mutually reinforcing. In addition, the use of mixed methods was intended to enhance stakeholder participation in the process, thus enabling the generation of valid and reliable results that incorporate good practices and lessons learnt for strengthening SRH related policy, programming, and advocacy initiatives.

2.2

Sampling design and techniques

The study was conducted in two sub-counties of Mpungwe (intervention) and Baitambogwe (control) in Mayuge district. Uganda Bureau of Statistics (2016) indicates that Mayuge district has a population of 473,239 of whom, 374169 (79.1%) are young people aged below 30 years. The selected study sub-counties were projected to have 45400 and 30600 for Baitambogwe and Mpungwe respectively (UBOS, 2020). According to the District Development Plan (2015/16-2019/20), Baitambogwe and Mpungwe have 7870 and 4896 households, respectively. Administratively, the sub-counties are structured as in table 1. Table 1: Administrative and Health Units in the study sub-counties. Sub-county Mpungwe Baitambogwe

Administrative Units No. Parishes 5 8

Health Facilities

No. Villages 27 32

Hospitals 0 1

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HCIV 0 0

HCIII 0 1

HCII 3 2

Total

Source: Muyuge District Development Plan 2015/16-2019/20 With the geographical spread of the administrative units and population in the study subcounties coupled with the constraints of time and financial resources, the study was based on a scientifically determined sample size using a Kish grid formula1 for sample size determination as explained here below.

n = Z2 PQ d2

Where: n is the required sample size; Z is the standard deviation of the mean at 95% confidence level; P is the %age of the households with a young person (10-24); Q is %age of the households without a young person or 1-P; D is the degree of marginal error (5%)

n=1.962X0.8X0.2 =245.86 0.052 According to the district development plan, at least 80% of the households have at least one young person. As such, the study estimated the value of both P and Q in the formula above at 80% and 20% respectively. Therefore, this formula yielded us a sample size of 246 households as per the calculation above. In each of the selected households, two interviews of a young person (10-24 years) and caregivers were conducted. Therefore, the actual sample size was meant to be 246 households. Thus, since the study targeted two respondents per household, a total of 492 interviews were envisaged. However, to cater for possible non-response rate, the sample size was scaled up by 10% bringing it to 541. It is therefore apparent that the response rate was 99.8%. The selection of the households to participate in the study was based on triangulated methods and techniques described here below. 2.2.1 Selection of the enumeration areas The sub-counties in which the study was conducted were purposively selected based on the intervention RAHU has implemented. However, from each of the sub-counties, 2 parishes were selected, and three villages selected from each parish through a multi-stage sampling technique based on simple random sampling methods. Study parishes and villages are indicated in table 2 below. Table 2: Study Parishes and Villages. Sub count

Parish

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Village

Muggi

Kasokwe, Miggi and Buwanuka

Buyere

Buyare, Musita and Nakitamu

Mpungwe Butte

Butte A, Butte B, and Nalwesambula B

Baitambogwe Igeyero

Igeyero A, Wagona, and Mukuta

The selection of the parishes and villages was guided by a stratified random sampling technique. At the parish level, all parishes in each of the study sub-counties were given numbers that were written on equal-sized pieces of papers to enable random selection using a rotary method. At the village level, the same procedure was used. In each selected village, a proportionate number of households was selected as explained here below. 2.2.2 Selection of the households A systematic sampling technique was applied to select the specific households that participated in the study. With the help of the respective LC 1 chairpersons, all households in the selected villages were compiled on separate lists to act as sampling frames. From each list, a proportionate sample was taken using the sampling interval for each village. Households, where there were no suitable young people, were substituted with their immediate neighbours. However, in six households, efforts to interview the corresponding young people were futile upon several callbacks. This explains why the number of caregivers is slightly higher than that of young people that participated in the study. 2.2.3 Selection of the actual respondents In each household, two respondents (a young person and caregiver) were targeted. In households where there was more than one qualifying young person, the one to be interviewed was purposively selected based on age, gender, and disability. This was intended to ensure effective representation of these categories in the study sample. The selection of respondents for qualitative data (key informants and FGD participants) was purposively based on their perceived knowledge of the phenomenon under study.

2.3

Methods and tools of data collection

This study utilized both primary and secondary data using a mix of qualitative and quantitative methods as described hereunder. 2.3.1 Household Survey Young people in sampled households and their caregivers constituted the primary participants in this study. These were interviewed using separate structured questionnaires (Annex 1 and 2) that had been programmed using the standard XLS format and administered electronically using the Open Data Kit (ODK) Collect android application for mobile data collection. The questionnaires were designed to capture quantitative data on access to and

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utilization of SRH services as well as the impact of the lockdown on household livelihoods. To minimize the non-response rate, the questionnaires were researcher administered. 2.3.2 Focus Group Discussions Beyond the quantitative sample, this study also collected qualitative data mainly through Focus Group Discussions and in-depth interviews with Key Informants. A total of eight FGDs (distributed across the sampled village) targeting male and female youths as well as caregivers were conducted. The FGDs were separated to allow free deliberations. FGD guides thematically tailored to the study objectives were used (Annex 3 and 4). The FGDs were moderated in the local language to mitigate the language barrier that may affect the effectiveness of the discussions. The FGDs were organized with the guidance of RAHU’s field staff as they targeted existing clubs/associations of vulnerable youth groups such as youth headed households, those living with HIV/AIDS, young people disabilities, teenage mothers, among others. Each FGD constituted between 6-12 participants and were held with strict observance of the COVID-19 prevention protocols, such as social distancing, wearing of masks and sanitizing / hand washing. Table 3 below indicates the number of FGDs that were conducted per respondent category. Table 3: Distribution of FGDs per category. FGD Category

People Living with HIV/AIDS (PLHIV) People with Disabilities (PWDs) Teenage / Young mothers Rural / Hard to reach areas Urban / slum areas Peer educators Total

Number Young people (10-24 Caregivers of young people years) 1 (M) - Mpungwe 1 (M) - Mpungwe 1 (F), Baitambogwe 1 (M, F) - Mpungwe 1(F) - Mpungwe 1(M) - Baitambogwe 1(F) – Baitambogwe 1(M, F) Mpungwe 7

1 (M, F), Mpungwe

1(F) - Baitambogwe

As indicated in the table above, a focus group discussion was conducted with RAHU’s field team (peer educators) to provide insights into the interventions that were provided, delivery modalities, how effective they were, challenges experienced, lessons learnt during the process and any recommendations to improve efficiency, effectiveness, sustainability, and equity, among others. 2.3.3 Key Informant Interviews Under the key informant category, relevant health workers and other community leaders were interviewed based on their involvement in the project/interventions as well as Page 7 of 118

knowledge and appreciation of SRH issues, particularly for young people. Customized key informant guides (Annex 5,6 and 7) were prepared in tandem with the study objectives. A total of 18 key informants who included health workers/staff at facilities providing SRHR to young people such as youth centres/corners as well as members of the District and SubCounty health team were interviewed. Annexe 11 provides the list of all key informants interviewed during this study. 2.3.4 Desk Review / Secondary Data The impact of COVID-19 has generally been written about in the available body of literature. For purposes of wider generalization of findings, several documents including inter alia, research reports, journal articles and other publications were reviewed. Also, the Consultants reviewed available project documents to get familiar with the intervention(s) that were provided, project area and the target population, delivery mechanism and partners engaged etc. The review of secondary data was undertaken using a data extraction form tailored to the study objectives. 2.3.5 Case Study Documentation While administering structured questionnaires or when conducting focus group discussions and key informant interviews, the team endeavoured to look out for unique cases for follow up with a more in-depth investigation and documentation using a case documentation guide (Annex 8). In total three cases were identified and documented and have been integrated into the findings to provide further evidence on the impact of COVID-19 and the lockdown. 2.3.6 Review of Health Facility Records The research team also visited two health facilities (Mayuge HC III and Baitambogwe HC III) and obtained data on the utilization of key sexual and reproductive health services by young people using a records review form (Annex 9). Among other things, this review captured demographic characteristics of the client e.g age, sex, disability status etc. as well as the service/product provided. To enable a comparative analysis of the impact of COVID-19 and the associated containment measures such as the lockdown, the team obtained data before, during, after the lockdown in each case taking three months. 2.3.7 Health Facility/Service Point Assessment In addition to obtaining data on utilization of SRH services at the two facilities, a separate Facility/Service point Assessment Tool/Form (Annex 10) was administered to In-charges or their designated staff. Among other things, this tool/form captured and documented health facility-specific data such as availability of youth-friendly services, staff available to provide SRH services to young people (including peer workers), available services (including outreaches), opening and closing hours during the lockdown, service availability during the lockdown, reasons for service outage, support received (e.g training, equipment, Page 8 of 118

product/commodity stocks etc.) and from whom as well as the support needed to enable the capacity of the facility to provide SRH services and information to young people.

2.4

Methods and tools of data analysis

2.4.1 Processing and Analysis of Quantitative Data Data analysis employed both quantitative and qualitative techniques. Quantitative data analysis was aided by SPSS (Version 26) that was used to generate descriptive and explanatory statistics which formed the basis of presenting and explaining the status of the study variables. 2.4.2 Processing and Analysis of Qualitative Data Thematic and content techniques aided by NVivo were used in analyzing information from key informant interviews and focus group discussions. This process followed three main steps namely: transcription, coding, and analysis. Completed transcripts were exported to Nvivo (Version 12 Pro) for coding and analysis. This process involved reading each transcript to identify responses and classify them under generalist themes in line with the research questions. While undertaking this painstaking process, the research team endeavoured to establish patterns and analytic reflections relating to the study questions using NVivo’s inbuilt memos. These memos further assisted in corroborating primary data with secondary data from document review.

2.5

Data synthesis, interpretation, and reporting

Completed quantitative and qualitative datasets from SPSS and Nvivo respectively were carefully compared and analyzed side by side to achieve a balanced conclusion regarding the findings. Thus, a unique technique known as side-by-side comparison was adopted. Quantitative data is reported first using descriptive statistics such as frequency tables, pie charts and graphs as well as cross-tabulations especially to compare the difference in outcome/impact between the project and control sites. The presence and strengths of the relationships between key study variables are also tested with the alpha threshold for significant results set at p = 0.05 (95 % confidence level). To complement the quantitative data, the case studies and other verbatim texts that exemplify young people’s voices and experience regarding access to and utilization of SRHR services and information during the lockdown are incorporated. Finally, concurrent presentation and discussion of the findings are done based on triangulated data sources in a manner that guides the Consultants to arrive at accurate, coherent, and balanced conclusions. This also forms the basis of drawing important lessons and possible feasible recommendations to inform future programming, policy, and advocacy.

2.6

Quality assurance and backstopping

The Consultant undertook various steps to ensure the quality of the processes and results in the implementation of the study. These included among others: recruiting and training Page 9 of 118

experienced research assistants and quality controllers/supervisors to handle data collection; pretesting the data collection tools; holding daily debriefs with the field team to discuss experiences and address any emerging challenges; maintaining timely and routine communication with the Client regarding the progress of the assignment including the accomplishment of key milestones. Furthermore, all expected deliverables such as data collection tools and reports were discussed with and approved by the Client through the Monitoring and Evaluation Department

2.7

Compliance with ethical guidelines

The execution of the assignment adhered to all relevant ethical requirements for researching human subjects. The requirements included but not limited to; informed consent, voluntary participation, confidentiality, and anonymity, and respecting the privacy of the respondents and the obligation not to do any harm. These were contained in a consent script that was read out to all participants in the local language to obtain their consent. All interviews with young people below the age of 18 only proceeded after obtaining consent from the caregiver and assent by the individual child/young person. Both caregivers and young people provided electronic signatures as proof of consent and assent to participate in this study, respectively. In addition to adhering to these standard guidelines, all members of the study team carried a letter of introduction from the Client signed by the head of Programs. Upon arrival in the district, the team paid a courtesy visit to the local leaders (CAO, RDC and DHO) to introduce themselves and obtain permission to conduct field activities. As a confirmation of the permission to conduct the study, the letter of introduction was endorsed by the District Health Officer (Appendix 12), and a copy of provided to each member of the research team. Before conducting interviews in the sampled villages, the research team presented copied of the endorsed letter to the LC1, as proof of permission to carry out household interviews.

2.8

Adherence to Covid-19 SOPs

Given that this study was being carried out during the COVID-19 pandemic, the research team adhered to COVID-19 Standard Operating Procedures (SOPs). Each member of the team appropriately wore a mask in addition to carrying a sanitiser. The social distancing between members of the research team and the study participants were strictly adhered to. For instance, while conducting focus group discussions, the research assistants ensured that the venue selected provided ample space to allow for social distancing between the participants. In addition, handwashing facilities (soap and water) or an alcohol-based sanitiser were made available at the venue where FGDs were held.

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3.0 PRESENTATION AND DISCUSSION OF RESULTS The overriding purpose of this study was to assess the impact of Covid 19 response on young people’s access to Sexual and Reproductive Health and Rights (SRHR) services and information with a particular emphasis on vulnerable populations. This Chapter presents the results of this investigation and is organized in key sections in tandem with the objectives of the study. Section One presents the socio-demographic characteristics of participants, Section Two is on Availability, Access to and Utilization of SRH services, Section 3 is on the Role of district and community leaders in promoting access to and utilization of SRHR services; and Section 4 is on the Effect of COVID-19 response measures on the livelihoods of households. The last Section presents the recommendations and draws conclusions from the study.

3.1

Respondents’ demographic characteristics

This study sought views from two primary categories of respondents namely young people (10-24 years) and their caregivers in selected households. These demographic characteristics such as age, level of education, religious belief etc. are important determinants of healthseeking behaviours. Table 4 below presents the demographic characteristics of interviewed caregivers, while those of young people are shown in table 5. Table 4: Demographic characteristics of caregivers Characteristic

no (N=273)

Below 25 yrs 25 to 30 yrs 31 to 49 yrs 50 yrs and above

4.40 14.65 54.21 26.74

12 40 148 73

Male Female

19.78 80.22

54 219

Never Attended School Primary Primary Secondary ‘O’ level Secondary ‘A’ level University

15.02 62.27 20.51 1.83 0.37

41 170 56 5 1

Age

Sex

Education

As observed above, more than half (54.21%) of the caregivers interviewed were aged 31-49 years, followed by those aged fifty and above, representing slightly more than a quarter (26.74%) of all caregivers interviewed. The proportion of caregivers below 24 years was only 4.4%. In terms of sex, the majority of the caregivers interviewed were female, accounting for 80.22%, while the males were close to a fifth (19.78%) of the total caregiver sample. By level of education, caregivers of primary level (62.27%) were the majority respondents, followed by secondary O’level (20.51%). Caregivers who had never gone to school were 15.02%, while only one caregiver had a university education.

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Table 5: Demographic characteristics of young people %

no (N=267)

10 to 14 15 to 19 20 to 24

37.83 41.20 20.97

101 110 56

Male Female

40.45 59.55

108 159

Never Attended School Primary Primary Secondary O’level Secondary A’level University BTVET School enrollment Yes No Parental status Yes, both alive Only father alive Only mother alive Both dead/total orphan Living with parents Yes, with both parents Yes, with father only Yes, with mother only None Disability None Physical Audio/hearing Speech Mental Employment Yes No

0.37 68.54 26.97 2.25 0.75 1.12

1 183 72 6 2 3

41.57 58.43

111 156

83.90 4.87 8.61 2.62

224 13 23 7

60.77 5.77 18.85 14.62

158 15 49 38

258 4 2 1 2

96.63 1.50 0.75 0.37 0.75

82.77 17.23

221 46

Characteristic Age

Sex

Education

For the young people, the majority of those interviewed fell within the 15-19 age bracket (41.20%), closely followed by 10-14 (37.83%). On the other hand, those aged 20-24 years represented slightly more than a fifth (20.92%) of all young people interviewed. In terms of sex, there were more female young people (59.55%) than their male (40.45%) counterparts. At the time of the study, the majority (58.43%) of the young people interviewed reported that they were not in school, and only 41.57% were in school. This is not surprising considering that at the time of conducting the study, only children of candidate classes had been allowed to return to school. In terms of the highest level of education, the majority (68.54%) of the Page 12 of 118

young people were of primary, followed by 26.97% of secondary. Only one young person among the entire sample had never been to school. Regarding parent status, the majority of the young people (83.90%) interviewed had both parents living, slightly more than a tenth (13.5%) were single orphans while just 2.62% were double orphans. Among those who had either both or one parent, a majority (60.7%) were living with both biological parents, close to a quarter (24.62%) were living with ether parent i.e., 18.85% with mother only, and 5.8%) with the father only. More than a tenth of all young people with a living parent was not staying with them at the time of the study. Only 2.25% of all young people interviewed had some form of disability, while the rest did not have any known disability. Among the few with disabilities, 4 were physical, 2 had hearing impairments, two had mental health-related conditions, while one was speech disability. In term of employment status, more than three quarters (82.8%) of all young people interviewed were not doing anything to earn money at the time of the study, while nearly a fifth (17.23%) were involved in work to earn money Figure 2 below shows that forms of wok that young people were involved in to earn money. Figure 2: Forms of paid work engaged in by young people. As observed above, the majority (39%) of those who were involved in paid work Petty trading 13% was in farming, followed by 39% Domestic work/chores petty trading (29%) and those doing domestic 13% Other chores (13%). Only a handful was involved in Business/Commercial commercial/business 29% Boda Boda/other activities (2%), boda-boda transport riding (2%) and salaried employment (2%). The other category involved building/construction work, chapati selling and hair plaiting. Results also show that of those who were engaged in work to earn a living, a majority (76.09%) were working before the lockdown, while close to a quarter (23.91%) started work during or after the lockdown. The reasons for engaging in work included the need to provide for personal basic needs as well as the need to support the family. 2%

Farming

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3.2

Availability, Access to and Utilization of SRHR Services by Young People

One of the objectives of this study was to assess the impact of COVID-19 and the national response on access to and utilization of Sexual and Reproductive Health and Rights for young people in Mayuge district. This section, therefore, presents the results of this investigation. Key issues studied in this regard include Availability of SRH services; Exposure to SRH information; Availability and utilization of Youth Friendly SRH Services as well as parents and young people engagement on SRH issues. 3.2.1 Availability of sexual and reproductive health services Availability of SRH is a key determinant of subsequent access and utilization. This study examined the extent to which essential SRH services were available to young people during the lockdown period as indicated in figure 3. Figure 3: SRH services availability during the lockdown.

SRH services availability during the lockdown Percentage

120 100 80 60 40 20 0

Services Always available; and free

Available sometimes; and free

Always available; and paid

Not available

All the health facilities visited were public/government-owned, two at the level of Health Centre III, while one was a Health Centre II. Provision of SRH services in normal times (before the lockdown) was generally good, with each of the services assessed, save for moon beads reportedly being provided by at least two out of the three facilities. As indicated in figure 4 above, the results further indicate that the provision of most of these services went on uninterrupted during the lockdown as most of the services were always available and free. Only three services namely: testing for RTI/STIs, sex and sexuality counselling and IUDs were not available at some facilities during the lockdown due to stockouts. On the other hand, female condoms were available during the lockdown, but at a cost.

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These results are largely supported by findings from qualitative interviews with key informants who mostly reported that SRH were mostly available throughout the lockdown. Indeed, the district put in place measures to continue the provision of health services, including SRH amidst the prevailing circumstances by ensuring the supply of SRH products and creating an enabling environment for health workers such as nurses to carry on their work. The district ensured the provision and delivery of SRH products to the health facilities as well as supervision to ensure the continuous running of the facilities. Carrying out sensitization through radio and megaphones to encourage young people to go for the services was also key (District Health Officer, Mayuge) No please, whenever the young people went to the health facility, the health workers would be available, there are also health workers who stay around these health facilities to attend to emergencies in case they arose (Reach A Hand Peer Educator) These efforts were buttressed by the support from/interventions by SRH focused CBOs/NGOs such as Living Goods, Reach A Hand Uganda, Rhites East Central, Reproductive Health Uganda, BRAC and the Busoga Cultural Institution among others: Rhites East Central was involved in mobilizing peer educators and volunteers to sensitize the young people about SRH services and patterning with CBOs to deliver services close to young people e.g in Baitambogwe sub-county they pattered with a CBO called BACHI to conduct community outreaches and dialogues (District Health Officer; Mayuge) Despite these coping mechanisms, some challenges in the delivery of SRH services to young people during the lockdown were reported. For instance, peer educators had to reduce their working hours to avoid conflicting with the designated curfew period. The COVID-19 imposed lockdown also caused some organizations to scale down most of their activities, much to the disadvantage of young people in need of services: We have been holding community dialogues with parents, we talk to them, and they also talk to us about SRHR services. However, because of the lockdown, school activities and community dialogues stopped (Reach A Hand Peer Educator) Some NGOs used to come here and would carry out HIV/AIDs and STIs testing but ever since the Covid-19 pandemic invaded us, they stopped. I only remember around August 2020, is when some health workers came and taught us about HIV/AIDS (FGD Young Mother, Buyere - Mpungwe Sub- County) The above testimonies paint a different picture about the continuity of SRH services during the lockdown, especially considering that civil society organizations play a critical role in the provision of SRH services by complementing the activities of government health facilities. Without the critical arm of these players, there is a likelihood that some young people in their areas of operation might have been left with an unmet need for SRH. Page 15 of 118

3.2.2 Access to and utilization of SRH services during the lockdown Access and to and utilization of health services is influenced by supply and demand-related factors. These include among others availability, ability to access (distance), affordability (income), provider and facility characteristics such as well as the quality-of-service provision as well as a range of demographic characteristics of the user (Bakeera et al., 2009; Buor, 2004; Gabrani, Schindler, & Wyss, 2020; Mojumdar, 2018; Wandera, Kwagala, & Ntozi, 2015). Another key factor in determining the utilization of health services is the need2. This study sought to assess the need for SRH services among young people in Mayuge, and figure 4 below illustrates the results of this investigation. Figure 4: SRH services needed during the lockdown.

Services needed

The results in the figure above indicate that the most needed SRH services during the lockdown were contraceptive methods (18.35%), HIV screening and testing (17.9%), SRH 17.98 18.35 counselling and information (10.86%) as well as pregnancy 0 5 10 15 20 Percentage testing (10.11%). On the other hand, the least needed services were treatment for abortion (1.5%), SGBV counselling and support (1.9%) and postnatal care (3.75%). Table 6 below compares the need for various SRH services by the respondents' age group. Treatment for abortion SGBV Counselling and support Post-natal care Maternity and child delivery Antenatal care (ANC) Testing for other STIs/UTIs Pregnancy testing SRH counselling and information HIV/AIDS screening and testing Contraceptives / FP methods

1.5 1.87 3.75 4.87 5.62 7.87 10.11 10.86

Table 6: Need for SRH services by age. Services Contraceptives HIV/AIDS screening and testing SRH counselling and information Pregnancy testing Testing for other STIs/UTIs Antenatal care (ANC) Maternity and child delivery Post-natal care

10-14 years 6.12 4.2 17.24 7.41 4.8 6.7 7.7 10

15-19 years 50 54.2 51.72 48.15 57.1 46.7 38.5 40

20-24 years 44.9 41.67 31.03 44.44 38.1 46.7 53.9 50

Total 100 100 100 100 100 100 100 100

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Health Care Utilization and Adults with Disabilities. Health-Care Utilization as a Proxy in Disability Determination. Washington (DC): National Academies Press (US); 2018 Mar 1. 2, Factors That Affect Health-Care Utilization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK500097/

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SGBV Counselling and support Treatment for abortion

0 0

80 100

20 0

The need for contraceptives/family planning methods, HIV/AIDS Screening, and testing, SRH counselling and information, pregnancy testing, testing for STIs/UTIs, SGBV counselling and support as well as treatment for abortion was higher among 15-19 age category, and lowest among those aged 10-24. On the other hand, the need for maternity and child delivery and postnatal care was highest among the 20-24 age category followed by those aged 15-19. The need for antenatal care was the same (46.7%) among the 15-19 and 20-24 age categories, and lowest among those aged 10-14. Results also indicate that young people aged 10-24 were more in need of SRH counselling and information than any other service. Generally, results show a significant relationship between young people’s age and the need for SRH services as evidenced by the Pearson Chi-Square value of 0.000. Figure 5 below compares the need for various SRH services in the intervention and control sites. Figure 5: Need for SRH services in intervention and control area.

services

SRH counselling and information Treatment for abortion Maternity and child delivery Testing for other STIs/UTIs Pregnancy testing 0

HIV/AIDS Maternit Testing Antenatal Pregnanc screening y and for other care y testing and child STIs/UTIs (ANC) testing delivery

60 Postnatal care

Baintambogwe

55.56

45.83

42.86

46.67

46.15

Mpungwe

44.44

54.17

57.14

53.33

53.85

100

120

SRH Contrace SGBV Treatmen counselli ptives / Counselli t for ng and FP ng and abortion informati methods support on 0 42.86 41.38 40 100

57.14

58.62

Percentage

As seen in the figure above, there was no striking difference in the need for different SRH services between the intervention and control areas of Mpungwe and Baitambogwe respectively, except for treatment for abortion where all those who needed this service were in Mpungwe. This is further confirmed by the results of the Pearson Chi-square value of 0.244 which is much higher than the alpha level of 0.05 for a statistically significant relationship.

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The need for SRH services alone is not sufficient and indeed is fruitless if not translated into a tangible initiative to seek for and utilize available services. Figure 6 below illustrates the percentage of young people who sought and obtained the needed services. Figure 6: Young people who sought and obtained SRH services. As observed in the figure 43.84 50 above, the percentage of 40 young people who 30 translated their need for 20 SRH services by actively 10 0 seeking them was higher in Yes Yes Mpungwe (53.95%) than Seek Obtain Baitambogwe (46.05%). Mpungwe Baitambogwe Similarly, there were more young people in Mpungwe (56.16%) who obtained the needed SRH services than their counterparts in Baitambogwe (43.84%). These findings point to a slight difference in the ability to seek for and obtain the needed service between the intervention and control areas. 60

56.16

53.95

46.05

Therefore, whereas the result of the Pearson Chi-square value of 0.044 is statistically significant at the alpha level of 0.05, this relationship is not strong to suggest that the difference in obtaining services is influenced by the presence or absence of an intervention. Basing on the calculated odds ratio (1.0 at 95% confidence interval) there is no likelihood that the observed variations in the level of access and utilization of SRH services can be attributed to any specific conditions in the intervention and control sub-counties. Furthermore, results of chi-square analysis by other demographic variables such as age, sex and level of education did not indicate any significant relationship. Figure 7 below shows the services sought and obtained by young people during the lockdown.

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Figure 7: SRH services sought and obtained during the lockdown. Treatment for abortion SGBV Counselling and support Post-natal care Maternity and child delivery Antenatal care (ANC) Testing for other STIs/UTIs Pregnancy testing SRH counselling and information HIV/AIDS screening and testing Contraceptives / FP methods 0

100

120

SRH Contrace HIV/AIDS Maternit SGBV counselli Testing Antenatal Treatmen ptives / screening Pregnanc y and Post- Counselli ng and for other care t for FP and y testing child natal care ng and informati STIs/UTIs (ANC) abortion methods testing delivery support on OBTAIN 92.86 100 91.67 100 92.86 100 100 100 100 100 SEEK

85.71

72.92

41.38

92.59

66.67

93.33

92.31

The three topmost sought services by young people in Mayuge district were antenatal care (93.33%), pregnancy testing (93%), and maternal and child delivery (92.31%). Contraceptives and treatment for abortion were sought by 85.71% and 75% of young people in Mayuge respectively. On the other hand, the least sought services were SGBV counselling, SRH counselling and information and testing for other STIs which were sought by 40%, 41.38% and 66.67% of the young people who expressed a need for them, respectively. Again, the Pearson Chi-square value of 0.450 is much higher than the alpha level of 0.05 for a statistically significant relationship to conclude that there is a difference between intervention and control areas regarding young people’s ability to seek SRH services. The majority of the young people interviewed reportedly obtained the needed services from a public health facility, followed by a private for-profit facility and private not for profit facility, accounting for 60.64%, 14.89% and 5.32%. These results are also consistent with previous studies on access to and utilization of SRH studies among young people. For instance, in their study on the impact of Youth-Friendly Family Planning Services in Uganda, Asingwire, Muhangi, Kyomuhendo, and Leight (2019) found out that more young people opted for public health facilities such as hospitals and health centres as their source of contraceptives. The authors attributed this to the establishment of separate youth-friendly service points in these facilities. In this study, young people whose need for SRH services was not translated into positive health-seeking behaviour were asked about the reasons underlying this phenomenon. As seen in figure 8 below, the dominant reason for not seeking services was lack of Page 19 of 118

knowledge/awareness on where to seek the service, accounting for (21.74) of all young people who did not seek services. Figure 8: Reasons for not seeking SRH services. Other reasons why young people did not seek the needed SRH services Perceived high cost of service during the lockdown included lack 8.7 of/challenges in accessing transport Fear stigma / discrimination 17.39 (19.57) and fear of the stigma No transport available 19.57 associated with the services (17.39). Didn’t know where 21.74 These findings are consistent with Other 26.09 results from other previous studies that have identified physical distance 0 5 10 15 20 25 30 to the health facility and costs of transport as impeding factors to young people’s access to SRH services. For instance, Mambo et al. (2020) recently reported that access to SRH was mainly inhibited by factors including lack of transport, distance from home to the facility, cost of the service and curfews. These issues were identified in qualitative interviews as one young person recollected: High transport costs

6.52

During the lockdown, some of us would not even go to the health facility, we mainly used peer educators and VHTs who would bring SRHR services nearer to the community members. For the SRHR services that they did not have, we would go without them. We could not even go to the facilities because they were very far> Imagine going to Kasutaime Health Centre II that is about 5km away from Buyere to pick a condom, you just stay home (FGD Teenage Mother – Buyere, Mpungwe S/C) In addition to the reasons for not seeking the SRH needed services, this study also examined the factors for not obtaining services among those who sought them. As indicated in figure 9, the biggest reason for not obtaining SRH services was the unavailability of health workers to provide services (40%), followed by the inability to afford the cost of the service and unavailability of the services sought each accounting for 20%.

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Figure 9: Reasons for not obtaining the services sought. These results were further highlighted in the qualitative interviews with key informants 20% 20% Needed service not in the health sector and focus available group discussions with young Could not afford the people and peer educators. For cost instance, the issue of longHealth workers not 20% available distance to the health facilities Other amidst a ban on public 40% transport coupled with the imposition of and strict enforcement of curfew was identified as a key impediment to access to and utilization of SRH services by young people as narrated: Access and utilization of SRH services during lockdown were low due to frequent stock-outs and restrictions on transport. Challenges to access and utilization of SRH were mainly transported to health facilities and yet there are long distances to health facilities. Private clinics must offer SRH services but in the villages, there are no clinics and where they are, services and products are very expensive for the majority of unemployed young people and general high poverty levels in the area. For example, a packet of condom with 3 pieces ranges from 1500 to 5000 depending on the type. This is quite high for most young people. (Secretary for Health and Social Services, Mayuge) In addition, there were concerns that some VHTs and health workers were not properly trained to appropriately handle issues of young people in a youth-friendly manner: With VHTs, there are fears that because these VHTS are recruited from within their villages the issue of confidentiality and disclosure prevents young people to report to them (District Health Officer) I was at Kasutaime Health Centre II and a young female person came. She had brought a child for polio immunization. She called me and told me “I feel like seeking a family planning service, but I fear these health workers.” I asked her the preferred choice of family planning and then referred her to the appropriate health worker. She got the best service she wanted and left a happy mother (Reach A Hand Peer Educator) These findings resonate with existing evidence about the role of youth-friendly interventions in attracting young people to seek and utilize services. Particularly, the quotation from the peer educator illustrates how the age of the provider can be a restrictive or facilitative factor for young people to utilize existing SRH services. Page 21 of 118

3.2.3 Access to SRH for vulnerable populations groups Regarding the provision of SRH services for vulnerable populations including young people with disabilities, those living with HIV/AIDS, teenage mothers among others, quantitative results do not reveal any significant variations. This may be explained by the low representation of these categories of people in the sample. For instance, young people with any form of disability constituted a meagre 3.37% of all participants, while the remaining 96.63% did not have any form of disability. Nevertheless, qualitative findings show that compared to their counterparts, vulnerable groups faced even greater challenges in accessing SRH services during the lockdown. Those with disabilities only came when they got some means of transport. When they could not because of transport difficulties, they only received information through the door-to-door mechanism. I for one helped about three young people with disabilities, offering them SRHR services at their homes because they could not walk to the health facilities during the lockdown (Reach A Hand Peer Educator) The young people living with HIV/AIDs were greatly affected by the lockdown measures. The time came and their drugs were out of stock, and they were left to go to distant health centres yet even the transport means were restricted (Reach A Hand Peer Educator) It was a bad situation for people with HIV because some of them were getting their drugs from Mayuge Health Centre III, and yet all transport means were grounded/restricted. It was therefore difficult for them to access SRHR services (FGD Teenage Mother, Buyere – Mpungwe Sub-county) As revealed in these verbatim extracts, transportation was a major hindering factor to access and utilization of SRH for vulnerable young people. This was exacerbated by long distances, a ban on public transport and the imposition of a curfew. For people in hard-to-reach areas such as islands, transport challenges further restricted the ability of the district health teams to conduct outreaches and ensure uninterrupted supply of SRH products and methods as was done in other areas. While this may not constitute systematic and deliberate discrimination, nonetheless it greatly disadvantaged affected populations unfairly. 3.2.4 Sexual behaviour, access, and utilization of contraceptives Given the well-established relationship between early onset of sexual intercourse and a host of SRH and development issues including teenage pregnancies, abortion, maternal and neonatal morbidity and mortality and school dropouts among others, this study investigated young people’s sexual behaviour during the lockdown and access to and utilization of contraceptives. As indicated in Table 7 below, a majority (82.40%) of the young people who participated in this study were not married/not in any union, while 10.49% were cohabiting and only 4.87 were married.

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Table 7: Sexual behaviour and use of contraceptives. Parameter Marital status (N=267) Never Married/not in union Currently married. Cohabiting Separated/divorced Ever had sex (N=220) Yes No Had sex during past 12 months (N=129) Yes No Used any contraceptives during past 12 months (N=107) Yes No

% 82.40 4.87 10.49 2.25

no 220 13 28 6

62.73 37.27

138 82

82.95 17.05

107 22

60.75 39.25

65 42

Among those who were never married majority (62.73%) reported that they had ever had sexual intercourse. All young people who were either married/cohabiting or reported to have ever had sexual intercourse were asked about engagement in sex during the past12 months (a period that also coincided with the lockdown). As indicated in the table above, more than three quarters (82.95%) of those reported having engaged in sex during the lockdown. Among those more than half (60.75%) used some form of contraceptive, while more than a quarter 39.25%) did not use any contraceptive to prevent pregnancy. Figure 10 below shows the use of contraceptives in the two sub-counties of Mpungwe and Baitambogwe. Figure 10: Engagement in sex and use of contraceptives during the past 12 months. 56 53.85

54 52

50.47 49.53

50 48

46.15 46 44 42

Mpungwe

Baitambogwe

Sex during 12 months

Contraceptive during 12 months

As seen above both engagement in sexual intercourse and contraceptive use during the past 12 months which coincides with the lockdown period were higher in Mpungwe than Page 23 of 118

Baitambogwe. Whereas the results in the figure above show that contraceptive use was slightly higher in the intervention area (53.85%) than the control (46.15%), the difference is not that striking. This is further confirmed by the results of Pearson chi-square analysis where the P-value of 0.384 is much higher than the alpha of 0.05 to suggest a statistically significant relationship. Likewise, analysis by respondent sex, age and marital status did not also show a significant relationship to explain the slight difference in the use of contraceptives by young people. Results on the contraceptive method used indicate that majority and indeed more than half of (55%) all the young people interviewed used male condoms, followed by injectables (26%) and withdrawal (8%) as shown in figure 11 below. Figure 11: Contraceptive method used during last 12 months. The least used contraceptive methods were female condoms (1%), lactational amenorrhea and implants. The limited Injectables, 26.15 use of lactational amenorrhea as a Male condoms, 55.38 contraceptive method is not surprising considering that majority of the young people who participated in this survey were not married/not in a union, and therefore more likely not to have had children or been breastfeeding. On the other hand, the preference for male condoms may be explained by their availability at the health facility as well as in the community where peer educators reportedly distributed them in open and public places such as trading centres and their homes: Lactational Withdrawal, 7.69 amenorrhea, 1.54 Implants, 3.08 Female condoms, 1.54

Pills, 4.62

We used to receive condoms at home, that we would give to the young people that needed them during the COVID-19 period. I believe every peer educator had condoms in their homes. So that was one of the measures that we had during the lockdown (Reach A Hand Peer Educator) One of the interventions during the lockdown was the distribution of male Condom by putting them at an open place in public like at trading centres and places of convenience (Secretary for Health and Social Services, Mayuge)

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Regarding the source of contraceptive method used, a majority (47.69%) of the young people interviewed reported that they had obtained them from public health facilities as shown in figure 12 below. Figure 12: Source of contraceptive during last 12 months. Private not for health facility

1.54

Don't know

3.08

Other peer educator/worker

3.08

Village health team (VHT)

6.15

Pharmacy/drug shop/clinic

7.69

Other

13.85

Private for-profit facility

16.92

Public health facility

47.69 0

The other sources of contraceptive methods for young people included private for-profit facilities, pharmacy/drug shop (7.69) and Village Health Teams (VHTs) who accounted for 6.15%, while a handful of young people reported that they obtained contraceptives from friends and partners. None of the young people interviewed reported obtaining contraceptives from RAHU peer educators where they existed. However, some of the young people interviewed during FGDs revealed that the contraceptive method used had been recommended to them by RAHU peer educators in their communities: We make use of Mr Eden, who is a peer educator here in Buyere and at the same time the VHT. If we need SRHR services, we approach him, he gives us some services for example sayana and condoms and refers us to the appropriate health facilities for other SRHR services (FGD Teenage Mother – Buyere; Mpungwe Sub-county) One of the pressing issues of concern to actors in the SRH sector is the problem of young people who are sexually active, but not using anything to prevent pregnancy. Previous studies have indicated a high unmet need for contraceptives among young women than the old ones. This study examined the reasons for not using any contraceptive method as shown in figure 13 below.

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Figure 13: Reasons for not using contraceptives during the last 12 months. Parents/caregivers objected

2.38

No money to buy

2.38

Facility hard to access

4.76

Preferred method not available

7.14

No need e.g married

7.14

Fear of side-effects

9.52

Wanted to have children

11.9

Other

26.19

Partner objected to use

28.57 0

The most common reason for not using any contraceptive method during the past 12 months, despite being sexually active was partner objection (28.57%), followed by the need to have children (11.9%) and fear of side effects (9.52%). Both absences of need for contraceptive use and lack of the preferred contraceptive method accounted for 7.14%. The other category was dominated by young people who did not know where to obtain contraceptives and those who lacked knowledge on contraceptives to use and how to use them. The relationship between contraceptive use is well established. This study assessed the rate of pregnancy among young people during the lockdown as shown in figure 14. Figure 14: Reported pregnancies during the past 12 months. The number of reported pregnancies among young people Yes 21% was 22 accounting for 21% of all participants. Of these, 7 were males who impregnated a girl, while 15 were No girls who conceived. In 79% terms of age, 8 of those who conceived/ impregnated someone was within the 15-19 brackets, while the rest (14) were in the 20-24 age bracket. The results further showed a strong relationship between contraceptive use and pregnancy/conception as evidenced by a Pearson Chi-Square result of 0.000.

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Furthermore, it was observed that of the 11 young people representing more than a tenth (15.71%) of those who reported having dropped out of school attributed it to pregnancy. Of these 6 were reported to have dropped out of school before the lockdown, while 5 dropped out of school following the lockdown. The likely impact of COVID-19 and the lockdown on the rate of pregnancy among young people and the associated consequences such as abortion and early marriages were also captured in qualitative interviews as exemplified here: Unwanted pregnancies increased due to the redundancy of young people caused by the closure of educational institutions. It is also possible that there are many more cases of pregnancy that were not reported (District Health Officer, Mayuge) There is a case at my place where one of my household members got pregnant during the lockdown. She, with the boyfriend, decided to abort and the consequences were severe. We went for a checkup and the girl revealed that she took traditional herbs to remove the fetus but instead things turned worse for her that she almost died (Reach A Hand Peer Educator) As hinted by the District Health officer, many other cases of teenage pregnancies could have gone unnoticed/unreported, owing to the COVID-19 restrictions that could have affected transport and other forms of information exchange between community people and the authorities such as the Police. 3.2.5 Exposure to SRHR Information and communication Access to accurate, timely and comprehensive information facilitates young people to make informed and responsible decisions concerning their sexual and reproductive health. This study assessed young people exposure to and access to SRH information, communication and education during the lockdown period as shown in table 8. Table 8: Exposure to SRH information during the lockdown. Parameter Seen/heard SRH messages (N=267) Yes No Visited by peer educator (N=220) Yes No Attended peer activity (N=107) Yes No

% 53.18 46.82

no 142 125

5.62 94.38

15 252

13.48 86.52

36 231

As indicated in the table above, slightly more than half (53.18%) of the young people interviewed revealed that they had heard/seen a message/communication on SR issues within a period of 12 months before the study, which also coincides with the lockdown period (April to June 2021). On the other hand, those visited by a peer educator within the same period were only 5.62%, while slightly more than a tenth reported having engaged Page 27 of 118

in/attended a peer activity on SRH issues. Figures 15, 16 and 17 below present results on the source of SRH information/communication, the channel as well as the content of the message. Correlation analysis on access to SRH information between the intervention and control area indicates no significant difference as confirmed by the chi-square result of 0.136. Figure 15: Source of SRH information during the last 12 months. As reflected in figure 15 2.11 majority (54.93%) of the RAHU peer educator/worker 2.11 young people obtained SRH information from health Community group/club 3.52 workers/counsellors, Other NGO / CBO (Specify) 4.93 followed by politicians/local Village Health Team (VHT) 5.63 leaders, other peer Other peer educator / worker 5.63 educators and VHTs, Local leader/politician 7.75 accounting for 7.75%, 5.63% and 5.63% respectively. The Others 13.38 other categories included Health worker / Counsellor 54.93 friends/peers, teachers, 0 10 20 30 40 50 60 parents, and other relatives, among others. Only 2.11% of young people who received SRH information mentioned that they obtained it from RAHU peer educators. Figure 16 shows the different channels through which young people received SRH information. Religious leader

Figure 16: Channel through which SRH information was received.

Phone

0.7

Poster/Signposts

4.93

Drama / video

5.63

Mobile megaphone

12.68

Television

12.68

Other

16.9

Radio

46.48 0

As observed above, the most dominant channel through which young people received SRH information during the last 12 months was radio (46.48%), followed by television (12.68%)

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and a megaphone (12.68%). There was no significant relationship between the channel and service uptake as evidenced by the Pearson Chi-Square value of 0.597. The quote below from a teenage mother collaborates the dominance of the radios in SRH information and communication during the lockdown: There were mostly radio talk shows on COVID-19 and other programs on family planning. They encouraged us to use appropriate family planning methods not to have very many children that we shall not be able to take care of (FGD Teenage Mother – Buyere; Mpungwe Sub-county) On the other hand, the least channel through which SRH information was received is the phone, accounting for a paltry 0.7%. This is probably related to the limited ownership of personal phones by young people in the age brackets interviewed. The other category includes word of mouth at school, church/mosque and at the health centre. Figure 17 shows the content of SRH information received during the past 12 months. Figure 17: Content of SRH information received by young people. According to the results in the figure above, more than How to prevent other STIs 1.41 three-quarters of young Other 2.11 people who reported that they received SRH How to keep good menstrual health 2.11 information/communication learned about how to How to make health SRH choices 2.11 prevent/avoid unplanned pregnancies, while slightly On gender-based violence/SGBV 2.82 more than a tenth received HIV counselling and testing 10.56 information on HIV counselling and testing. How to prevent/avoid pregnancy 78.87 These findings resonate with the broader SRH campaign in 0 20 40 60 80 100 the country with an emphasis on the prevention of unplanned pregnancies and HIV/AIDS infection. 3.2.6 Availability and utilization of SRH youth-friendly services Under the Health Sector Strategic Plan (HSSP) III (2010/11-2014/15), the Health Sector Development Plan 2014/15 – 2019/20 and the Costed Implementation Plan for the same period, the Government of Uganda through the Ministry of Health established Youth Corners/centres in selected government hospitals and health centres in various parts of the country. This was intended to improve access to and utilization of adolescent-friendly reproductive health services including family planning. This study assessed the availability, access to and utilization of these services during the lockdown. As shown in table 9 young people who knew where youth-friendly services are provided constituted almost a quarter (24.34%) of the total sample. Page 29 of 118

Table 9: Availability and utilization of youth-friendly RSH services. Parameter Know where YFS are provided (N=267) Yes No Last visited youth YFS point (N=65) 0-6 months ago 7-12 months ago More than a year Never

% 24.34 75.66

no 65 202

21.54 15.38 12.31 50.77

14 10 8 33

Out of the total number of young people who knew where youth-friendly SRH services are provided, the majority constituting slightly more than half of the total number had never visited the facility to seek services. However, slightly more than a fifth (21.54%) visited had visited a youth-friendly facility within a period of six months before the study, while 15.38% reported having last visited a youth-friendly facility within 7-12 months before the study. Figure 18 below shows the services obtained by young people who had ever visited a place exclusively providing SRH services to young people. Figure 18: Services obtained by young people during the lockdown.

As indicated in the figure above, a majority (43.75) of the young people who reported to have ever visited a youth-friendly facility obtained contraceptives/methods of family planning, followed by those who received HIV/AIDS screening and testing services, pregnancy testing and SRH counselling and information, accounting for 18.75%, 9.38% and 9.38% respectively. A paltry 3.13% of young people who visited a youth-friendly facility obtained treatment for abortion, while some 6.25% did not receive any services.

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Despite the recognized role of dedicated service points where young people can access and utilize SRH services, authorities were concerned about the sustainability of these facilities explained by the District Health Officer: On the issue of youth corners, I agree they are very important and necessary but have remained nonfunctional across the district due to staff and space inadequacies at the facilities. Where they have been established, it became difficult to sustain and maintain them (District Health officer, Mayuge) The concern of Mayuge’s DHO is not unique, given that in many places where they have been established facilities that provide youth-friendly services continue to grapple with challenges of funding and space. The Midline report Youth Friendly Services in Uganda found that only 13% are the services provided in stand-alone premises, in what may be described as youth centres, while the majority (60.9%) were housed within the main health facility building. 3.2.7 Care-giver –Young persons’ engagement on SRHR services Both research evidence, international policy and best practice underscore the central role that parents play in promoting positive sexual behaviour and outcomes in their children (Aventin et al., 2020). Indeed, parents-caregiver interaction on SRH issues has been shown to play a vital role in shaping young people trajectories from childhood, through adolescence to adulthood. It plays a vital role in challenging negative attitudes, beliefs, and perceptions that that may be detrimental to children’s SRH lives (Dessie, Berhane, & Worku, 2015; Maina, Ushie, & Kabiru, 2020; Othman et al., 2020). However, evidence also suggests that interaction is challenging worldwide especially in communities where this culture is not well established and where narratives on sex and sexuality are held sacred and shrouded in secrecy. This study examined various issues about parents’-young people’s engagement on SRH issues as shown in table 10 below. Table 10: Caregiver perceptions on young people’s access to SRH services. Parameter Okay to discuss SRH with young people

(N=273) Yes No Do you feel free to discuss SRH issues with young people (N=273) Yes No Who should discuss SRH issues with young people (N=261) Parents/caregivers Health facility/health worker Auntie / Uncle Teacher Peer leader

% 261 12

no 95.60 4.40

82.78 17.22

226 47

88.89 4.60 3.07 2.68 0.38 0.38

232 12 8 7 1 1

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Other At what age is it okay to discuss SRH issues with young people (N=261) Below 10 years 10 – 14 years 15 – 17 years 18 years and above

3.83 55.94 28.35 11.88

10 146 74 31

According to the results above, a majority (95.60%) of the parents/caregivers interviewed agree that it is okay for parents to discuss SRH issues with young people under their care. Only 4.40% did not think it was okay. Furthermore, a majority (88.78%) reported that they feel free to initiate discussions on SRH with young people, while 17.22% fear doing so. These divergent views were captured in qualitative interviews with caregivers as demonstrated below: Can you go and tell your children that condoms are here, whenever you need to have sex, you can use them, really (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) We as parents need to be bold and tell off these young people. We need to tell them the right thing so that they do not make mistakes when they grow up. You see, whenever we do not tell them, we get issues like teenage pregnancy and other SRHR issues (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) These two extracts exemplify the contrasting views regarding the involvement of young people in SRH issues, that is pervasive in most communities. The first quote reflects the common misconception that discussing SRH issues with young people is equivalent to a direct/open encouragement to engage in premarital sexual relationships that are generally outlawed by most cultures and religion which most people hold in high regard. On the other hand, the second quote seems to espouse appreciation of the notion of age-appropriate information. Regarding who should initiate these discussions, more than three-quarters of respondents reported that parents/caregivers should take the lead. Health workers, aunties and teachers were also recognized as key players in such issues. Only one caregiver mentioned that peer leaders should talk to young people about SRH issues. On the issue of the appropriate age at which SRH issues with young people should be initiated, more than half (55.94%) of all the caregivers interviewed mentioned 10-14 years, followed by those that consider 15-17 years (28.35%) to be the recommended age for discussing SRH issues with children. These contrasting views were also expressed in FGDs: It should be at 16 years because that’s when you can inform them about the consequences of impregnating someone or getting pregnant such as getting imprisoned or living in poverty (FGD Caregiver of PWD – Buyere; Mpungwe Subcounty)

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I think talking to young people/ our children about SRHR should start at 13 years of age because they tell us that at 13, some girls have their menstruations. The boys also develop changes (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) At 13years, a girl can conceive, at 14 years, she can conceive, so we need to start at 13 years to talk to our children because we understand that at that age, they have started developing sexually (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) The least recommended age for discussing SRH issues with children was below ten years of age, while those that think that SRH issues with children should be discussed at age 18 or beyond were slightly more than a tenth. These findings reveal controversies or rather mixed opinions about the issue of SRH in general and young people’s involvement in particular, as already suggested by the existing literature. Table 11 shows results on parents’/caregivers’ engagement with young people on SRH issues during the lockdown. Table 11: Discussion of SRH issues with young people during the lockdown. Parameter Ever discussed SRH issues with young people (N=273) Yes No Discussed SRH issues with young people in the past 12 months (N=194) Yes No Who initiated SRH talk with young people

(N=165) Myself / spouse The young people Other

% 194 79

no 71.06 28.94

165 29

85.05 14.95

93.94 4.85 1.21

155 8 2

Of the total number of caregivers interviewed, a majority (71.06%) reported that they had ever discussed SRH issues with young people. Among those who had ever discussed SRH issues with young people, a majority (85.05%) reportedly had an interaction on SRH issues with young people under their care within 12 months before the study, which coincides with the lockdown, while did not have such discussion. It is further observed that most of these discussions were initiated by parents, as opposed to child/young people led. This is reflective of a predominantly adult led approach to decision making that is common in most African societies where the notion of child/young people’s participation is not yet well established. Caregivers/parents who reported to have discussed sexual and reproductive health issues were asked about the subject of their interaction. As indicated in figure 19 below more than three-quarters of those discussions were on how to avoid unplanned pregnancies.

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Figure 19: Subject of SRH discussion with young people. The dominance of unplanned pregnancies 2.42 3.03 4.24 in caregiver-young HIV counselling and testing people interaction on How to prevent other STIs SRH probably mirrors the collective concern How to make healthy SRH about risk for choices unplanned pregnancies How to keep good menstrual health among young people of On gender-based school-going age. 87.88 violence/SGBV Indeed, during and the Other period after the lockdown, there have been reports of an increase in cases of teenage pregnancies in various parts of the countryiiiiiiivvvi. 1.21

0.61

How to prevent/avoid pregnancy

0.61

As earlier reported, more than a quarter (29%) of caregivers interviewed reported that they did not discuss SRH issues with young people under their care during the past 12 months including the lockdown period. Figure 20 below shows the reasons for not doing so. Figure 20: Reasons for not discussing SRH with young people. 25 20.69

Axis Title

17.24

15 10.34

10.34

10 3.45

5 0 Don’t feel Didn’t free to talk have time to them Series1

20.69

10.34

Can discover on their own 10.34

It’s not They are I am not They are culturally not free informed still young appropriat with/don’t about SRH e trust me issues 17.24

3.45

10.34

Other 17.24

As observed above the majority accounting for slightly more than a fifth of all caregivers interviewed reported that they did not have time to talk about SRH issues with young people under their care, while 17.24% considered that it was inappropriate to talk to young children about SRH issues given their age. Other reasons why caregivers did not interact with young people on SRH issues include perceptions that young people can discover on their own, not Page 34 of 118

being informed and feeling confident to talk about SRH, and concerns of trust on both ends to facilitate open interaction about sexual and reproductive health. My children talk to me on issues of SRHR, but other children do not because first, the parents are not friendly to their children and children see their parents as a burden to them. A child will tell you “I am fed up with my parents” and you even wonder. So, how do you expect people living like enemies to talk on issues of SRHR care (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) These findings are somewhat consistent with previous studies that show issues of sex and sexuality in most African communities are regarded as sacred and therefore rarely openly discussed especially with young people. As a result, many young people are left to discover on their own, which often comes along with negative ramifications such as teenage pregnancies and associated problems such as abortion, school dropouts, early marriages, and reduced prospects of living a good life.

3.3

Role of district and community leaders in promoting SRHR during the pandemic

Uganda operates a decentralized system of service delivery including in the health sector. Under this system of administration and governance, local governments through their respective structures are at the forefront of service including in the health sector. They contextualize, adapt, and implement policies, strategies and interventions developed at the national level; and scale up health interventions at the district level (Bulthuis et al., 2021). Given their proximity to the people, the district and other community leaders can also play a fundamental role in health promotion by mobilizing people to access and utilize available services including SRH. With the onset of the COVID-19, local governments at the district and sub-county levels were at the forefront of the fight by enforcing and monitoring the implementation of the Ministry of Health standard operating procedures for the prevention of the spread of the virus. This study sought to assess the role of district and community leaders in facilitating access to sexual and reproductive health services for young people during the COVID-19 pandemic period, particularly during the lockdown which spanned from March to June 2020. Interviews with young people showed that district and other community leaders were not a dominant source of information on SRH during the lockdown as shown in table 12 below, where only 7.75%of young people obtained SRH information from local leaders/politicians, 5.63% from Village Health Teams and 2.11% from religious leaders. Table 12: Young people’s source of information of SRH during the lockdown. Parameter Source of information on SRH during the lockdown (N=267)

% 54.93 2.11

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no 78 3

Health worker / Counsellor RAHU peer educator/worker Other peer educator/worker Other NGO / CBO (Specify) Village Health Team (VHT) Community group/club Religious leader Local leader/politician Others

5.63 4.93 5.63 3.52 2.11 7.75 13.38

8 7 8 5 3 11 19

When asked about the role that district and community leaders played in facilitating young people’s access to SRH during the lockdown, the majority (72.16%) of the caregivers/parents interviewed reported that no assistance was provided as indicated in figure 21 below. Figure 21: Community leaders’ support towards SRH of young people. Among those who could attest to the role of 70 leaders in facilitating 60 access to SRH, slightly 50 more than a tenth 40 (10.26%) mentioned provision of 30 sensitization and 20 10.26 9.16 education, while 9.15% 6.59 10 0.73 talked about the 0 issuance of movement No assistance Provided Issuing of Don’t know Supply of SRH at all awareness & movement products permits. On the other sensitization permits hand, 6.5% of caregivers interviewed did not know any form of support extended by district and community leaders to facilitate young people’s access to and utilization of RH services during the lockdown. 80

72.16

To further understand the role of district and community leaders in facilitating young people’s access to SRH during the lockdown qualitative interviews were held with different categories of stakeholders including local leaders and peer educators. Findings reveal that district officials put in place various strategies to ensure continuous provision of SRH services to those who needed them, despite the challenges presented by the COVID-19 pandemic and the lockdown. The excerpt below from an interview with the DHO explains some of these measures. The district covid-19 task force headed by the RDC allowed nurses with their work identity cards to move freely to and from the health facilities. They were referred to as essential workers and this enabled health facilities to open for young people to access the needed SRH services. However, the cost of transport more than doubled which worsened the problem services (District Health Officer, Mayuge) Page 36 of 118

These views above were reiterated by other respondents as reflected in the quotations below from the Secretary for Health and Social Services and another from a RAHU Peer Educator: The district through the Taskforce facilitated processing or securing written and oral permissions for young people who wanted to access the services at different facilities. For example, those who wished to go for ant and post-natal care and expectant young mothers were supported (Secretary for Health and Social Services, Mayuge) Yes, the local leaders like LCIs would give reference letters for people who wanted SRHR services during lockdown (Reach A Hand Peer Educator) As captured in these testimonies, while the district leadership may not have been directly involved in the provision of SRH services to young people during the lockdown, a lot was done to eliminate the supply and demand-related barriers to access and utilization. Other interventions undertaken by the district include supporting information dissemination about the availability of services at the health facilities during the lockdown, coupled with conducting outreaches to extend services to young people in their communities. We put announcements on the radio to let young people know the services that were available at health facilities and assure them that the facilities were open and encouraged them to go there and seek these free services (District Health Officer, Mayuge) It was also reported that during the lockdown, the district health team enlisted the support of the VHTs in providing SRH services to young people as Recruitment and training of VHTs to help in the sensitization of SRH services at the grass-root level. The interventions were quite effective especially for VHTs who did door to door delivery of SRH services like simple and short-term family planning methods for mothers (Secretary for Health and Social Services, Mayuge) Used VHTs and other volunteers to take information and products directly to the users (District Health Officer, Mayuge) The use of VHTs was also good because even during the lockdown, VHTs would visit us and give us SRHR information (FGD Teenage Mother – Buyere, Mpungwe Subcounty) The Village Health Teams are an important component of the community health system in Uganda. In particular, the VHTs support the health workers in extending health services including sexual and reproductive health to remote areas that are often marginalized due to the lack of adequate staff at health facilities. As such, enlisting the support of VHTs to be an important strategy in delivering SRH in a period of crisis such as the COVID-19 imposed lockdown.

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Another role of the district in facilitating access to SRH services to young people was ensuring the continuous supply of SRH products to health facilities to ensure uninterrupted delivery of services including by VHTs whose stocks were replenished: The district ensured the provision and delivery of SRH products to the health facilities as well as supervision to ensure the continuous running of the facilities. Carrying out sensitization through radio and megaphones to encourage young people to go for the services was also key (District Health Officer, Mayuge) As earlier reported from the results of the facility assessment, most of the facilities visited were able to continue the provision of most of the SRH services that were routinely provided to young people before the lockdown. This ensured that young people in need of services continued to enjoy a wide range of SRH methods and products with minimum interruption due to stockouts. Despite this resilience exhibited by the district health structure to facilitate the continuous provision of SRH services, some challenges were experienced. For instance, delivery of health products and undertaking outreaches did not cover hard to reach areas as explained by the DHO: These interventions however did not cover the entire district as some sub-counties are very hard to reach due to their geographical nature. These are Malongo located in a forest reserve and Jaguzi sub-county which is surrounded by 6 islands. These places largely remained without SRH services during the lockdown (District Health Officer, Mayuge) As has been reported in previous studies, vulnerable young people including those in hardto-reach areas are often disproportionately affected by SRH issues. Therefore, a limited supply of SRH services during the lockdown would probably result in a disproportionate prevalence of SRH related problems such as teenage pregnancies, early marriages, and the associated consequences such as unsafe abortions, school dropout and reduced socioeconomic prospects.

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3.4

Impact of COVID-19 response measures on household livelihood

The outbreak of COVID 19 and its associated response measures have had an unprecedented effect on many sectors of the economy globally. In Uganda, since the reporting of the first case on 21st March 2020, the effect of the pandemic has continued to bite harder and deeper across all the sectors of the economy. Despite the noticeable uniformity in the COVID-19 response measures across countries, the effects of the pandemic and its associated response measures have varied across countries and specific communities. Whereas there is a growing body of literature on the effect of COVID 19, context-specific data in terms of targeted geographical areas remains critical for responsive programming. It was against this background that this study analyzed the effect of COVID-19 and its associated response measures on the household livelihood dynamics in Mayuge as presented here below. 3.4.1 Household’s livelihood dynamics Given its rural setting, the majority of the households in Mayuge district derive their livelihood from farming. According to the District Development Plan 2014/15-2019/20, agriculture employs about 97% of the district population with fishing and commerce as the subsidiary sources of livelihood for small proportions of the population. Primary data indicates that 77.3% of the households relied on farming as their main source of livelihood with 13.6% on commerce. Other mentioned sources of livelihood included casual labour, salaried employment, remittances, and artisan/vocational related services as shown in figure 22. Figure 22: Major sources of income for the household 2%

Farming 14%

Trading (business) Causal Labourer

77%

Salary employment Artisan / vocational Remittances/aid

The degree to which COVID-19 affected the population’s sources of livelihood formed the central part of this study with particular focus on household income and expenditure, food security, jobs and employment, domestic relations and SGBV as well as access to and

utilization of SRH services as presented hereunder. 3.4.2 Impact of COVID-19 on household income and expenditure The effect of COVID 19 on income and expenditure patterns and the associated impact on other livelihood indicators such as food security and provision of other basic needs is undisputable. This study assessed the impact of COVID-19 and its containment measures on Page 39 of 118

household income and expenditure. Primary data shows that the majority (84.6%) of households were earning not more than UGX 350,000 per month, while those earning more than 350,000/= were 15.4% as shown in figures 23 and 24 below. Figure 23: Estimated average monthly income. 40.0

37.0

35.0 30.0 25.0

22.3

20.0 15.0

12.8

12.5

10.0

7.0 4.0

5.0

3.3

1.1

0.0 1

< 50,000

50,000-150,000

150,001-250,000

250,001-350,000

350,001-450,000

450,001-550,000

550,001-1,000,000

>1,000,000

Households with an average monthly income of over 1 million were only .1%. regarding expenditure, results indicate that majority of households (45.8%) incurred between 50,000/= to 150,000/= on average per month. Combined, households that spent not more than 350,000/= on average per month were 93%, while those with an average monthly expenditure or more than 1,000,000/= were only 0.7% as indicated in figure 24 below. Figure 24: Estimated average monthly expenditure. 50.0

45.8

45.0 40.0 35.0 30.0

25.0

20.9 16.9

20.0 15.0

9.9

10.0 5.0

1.1

1.8

2.9

0.0 1

< 50,000

50,000-150,000

150,001-250,000

250,001-350,000

350,001-450,000

450,001-550,000

550,001-1,000,000

>1,000,000

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0.7

As shown in figures 25 and 26 below a majority of households in Mpungwe (85,6%) and Baitambogwe (83.5%) reportedly earned not more than UGX 350,000 per month and 93.1% and 93.7% of residents spent not more than UGX 350,000. Figure 25: Estimated monthly average income by sub-county. 45.0 40.0

38.3

35.9

35.0 30.0 22.8

25.0 20.0 15.0

21.9 15.2

13.3

11.7

10.2

10.0

7.0

6.9 3.5

5.0

4.7

2.8

3.9

0.0 Mpungwe

Baitambogwe

< 50,000

50,000-150,000

150,001-250,000

250,001-350,000

350,001-450,000

450,001-550,000

550,001-1,000,000

In both the sub-counties, the majority of the surveyed households i.e., 35.9% in Mpungwe and 38.3% in Baitambogwe were earning between 50,000/= to 150,000/= on average per month, while those who earned 550,000/= to 1,000,000/= were 2.8% and 3.9% in Mpungwe and Baitambogwe respectively. Figure 26 below compares the reported average monthly expenditure in the intervention and control sub-counties. Figure 26: Estimated monthly average expenditure by sub-county. 50.0

46.1

45.5

45.0 40.0 35.0 30.0

25.0 20.0 15.0

21.1

20.7 14.5

19.5

12.4

7.0

10.0 5.0

1.4

3.5

0.8

0.0 Mpungwe

Baitambogwe

< 50,000

50,000-150,000

150,001-250,000

350,001-450,000

450,001-550,000

550,001-1,000,000

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250,001-350,000

2.3

As in the case of income, the majority i.e., 45.5% of households in Mpungwe and 46.1% in Baitambogwe reportedly spent 50,000/= to 150,000/= on household items per month, while those who spent more than 1,000,000/= were 3.5% and 2.3% in Mpungwe and Baitambogwe respectively. There were no significant variations in estimated average monthly income and expenditure between the two sub-counties as evidenced by the Pearson Chi-Square value of 0.938 and 0.793 for income and expenditure, respectively. The Covid-19 pandemic and its associated prevention measures have led many people to experience a reduction in their income due to job and livelihood losses, reduced flow of remittances, loss of market and demand for domestic products, among others. This study investigated these issues presented below. Figure 27: Change in household income during the lockdown. 60

53.85

50 40

35.53

30 20 10

6.23 1.83

2.56

0 Increased a lot

Increased a little

Remained the same

Decreased a little

Decreased a lot

As observed in figure 27 above, a majority (89.3%) of the surveyed households a decrease in total income received during the lockdown as shown. Most of these households (68.1%) however reported that income received increased after relaxation of the lockdown measures that were put in place. On the other hand, more than a quarter (31.5%) of households reported that there was no change in income following the easing of the lockdown. The results do not suggest any relationship between the sub-county and a change in household income during the lockdown as evidenced by the Pearson Chi-square of 0.531. However, there is evidence of a relationship between change in household income during the lockdown and the main source of income of the household head (0.023), as well as the main source of income for the household in general (0.013). This is probably because in most cases, the source of income for the head of the household would also double as the main source of income for the household at large. Figure 28 below shows the reported impact of the lockdown on household expenditure.

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Figure 28: Change in household expenditure during the lockdown. As observed above, 80.2% of surveyed households 50 reported an increase in spending during the 40 lockdown, a trend that 31.1% of households 30 26.37 reported as continuing 20 even after relaxation of the lockdown measures, while 7.69 10 6.59 5.49 28,6% and 40.3% reported no increase and a decrease 0 in spending following the Much more A little more The same A little less Much less relaxation of the lockdown. The findings show that the bulk of spending during the lockdown was on basic necessities such as food, healthcare, clothing as well as utilities such as power and water. 60

53.85

Furthermore, the majority of households (66.3%) were of the view that the economic conditions of their households were worse than those of other individuals in their towns of residence. Unlike income, the results pointed to a relationship between the sub-county and change in expenditure during the lockdown with a P-value of 0.009. similarly, there was a relationship between the change in expenditure during the lockdown and the main source of income for the head of the household (0.012) and the main source of income for the household (0.027). Households also stated that the Covid-19 pandemic and its associated prevention measures especially the lockdown caused many challenges that made it difficult for households to afford/get at least three meals a day (75.5%), access markets to buy basic needs (89.74%), access markets to sell items (85.4%), care for sick family members (83.9%), provide for needy family members (81.3%), access (87.2%) and pay (85.3%) for healthcare services. 3.4.3 Impact of COVID-19 on household food security Uganda’s COVID-19 response measures respected agriculture as one of the key sectors that should not be interrupted. As such, agricultural-related enterprises such as agricultural markets and shops, vehicles transporting agricultural products were allowed to continue operating. However, the closure of other sectors such as education from which different sections of the population derived their livelihood inevitably affected the household food security particularly in respect to access to adequate quantities and quality of food. Primary data reveals that homegrown food was the main source of food for 85.7% of the respondent households, while 13.9% relied on the market for their food supplies. The World Health Organisation recommends three meals a day for an adult and more than three meals Page 43 of 118

a day for the children and this was used as a benchmark to assess the household food security in the study area. In this regard, the study established that in the majority (96.6%) of the households, both adults and children had more than two meals a day. Whereas in 3 (1.1%) of the households, adults were reportedly having one meal a day. None of the households in the study indicated that children had less than two meals as presented in figure 29 below. Figure 29: Number of meals had a day by adults and children. It is important to note that the study did not reveal any significant variations between the treatment and control subcounties as the number of meals had by both adults

60 50

Axis Title

40 30 20 10 0 One

Two

Three

More than three

1.1

47.2

49.4

2.2

27.1

20.9

Adults Children

and children were almost the same as presented in figure 30 below. Figure 30: Number of meals consumed a day by sub-county. 60.0 50.0

Axis Title

40.0 30.0 20.0 10.0 0.0

Mpungwe

Baitambogwe

Mpungwe

Adults

Baitambogwe Children

One

0.7

1.6

Two

46.2

48.4

28.3

25.8

Three

51.0

47.7

51.7

52.3

More than three

2.1

2.3

21.9

In Mpungwe sub-county, in the majority (51.0%) and 46.2% of the households, adult members were reportedly eating three (3) and two (2) meals a day, respectively. Whereas the households whose adult members were reportedly having more than three (3) meals every Page 44 of 118

day were reportedly few (2.3%). 20% and 21.9% of the households in both Mpungwe and Baitambogwe respectively were reportedly affording more than three (3) meals a day for the children. Almost the same proportion (51.7% and 52.3%) of households reported that children were having three (3) meals a day in both Mpungwe and Baitambogwe sub-counties, respectively. Table 13: Chi-square results on the number of meals per day by sub-county Chi-Square Tests Value

Asymp. Sig. (2sided)

.723a

.868

Likelihood Ratio

.728

.867

Linear-by-Linear Association

.294

.587

N of Valid Cases

273

Pearson Chi-Square

From the descriptive data presented above, it is apparent that the food security situation has fairly been the same across the study sub-counties. This is further confirmed by the Pearson Chi-square value of 0.868 that is way above the alpha level of 0.05 for a statistically significant relationship as shown in the Chi-square table 13. Despite the fairly food secure households at the time of this study, 20.3% and 28.3% of the households in Baitambogwe and Mpungwe sub-counties respectively revealed that they could not afford a minimum of three (3) meals a day during COVID-19 lockdown. This was revealed by almost the same proportion of the households in both intervention and control sub-counties as shown in figure 31. Figure 31: Household food security situation during COVID 19 Lockdown. The findings of this study disagree with Kansiime et al (2021) that the lockdown 20.3 Couldn't Afford at least 3 meals a day worsened the 28.3 household food situation in Uganda. Instead, the study 79.7 Afforded at least 3 meals a day findings are 71.7 consistent with the projections made by 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 Famine Early Baitambogwe Mpungwe Warning Systems Network (FEWS Net) that the lockdown measures would affect household food security more in urban than rural

Chart Title

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areas. The identification of agriculture as one of the critical sectors deliberately shielded from the restrictive COVID 19 control measures, reduced the effects of the pandemic on household food security. As projected by FEWS NET, households with access to their own produced food indeed suffered minimal effects of the pandemic and its containment measures. However, for this study, food security during the lockdown was reportedly stable among households irrespective of their main source of food. Majority of the households irrespective of their major source of food afforded at least three meals a day as shown in figure 32 below. Figure 32: Household food security by the source of food. In the context of a rural setting like 100.0 100.0 92.1 Mayuge, participants in FGDs revealed that 80.0 72.6 households rely on 60.0 multiple sources of food and that this is a 40.0 27.4 strong factor that influences food 20.0 7.9 security. This 0.0 0.0 notwithstanding the Own production Market Labour exchange association between Afforded at least 3 meals a day Couldn't Afford at least 3 meals a day household food security and source of food cannot be overstated. A Chi-square analysis of this relationship reveals a significant relationship though not strong as shown in the Chi-square table below. 120.0

Table 14: Chi-square result on food security by the source of food

Despite the significant association between the source of food and household food security, data from the two sub-counties indicated that households were not severely hit by food insecurity due to the COVID-19 preventive measures. Participants in the FGDs and key informants revealed that whereas there was sufficient food in the rural areas, in urban a large population of people suffered. This is consistent with the findings of Kansime et al (2020) that

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COVID 19 and its control measures increased food insecurity for the urban populations than their rural counterparts. The study however established that there was a lot of anxiety over food insecurity due to COVID 19 in 82.1% of the households that participated in the study. As a result, households reportedly devised means of sparingly utilizing their food stocks as the effect of the pandemic was still largely uncertain. The majority (87.5% and 60.4%) reported having changed diet and skipping a meal respectively because of the anxiety over the effect of the pandemic on household food security. In 42.5% and 48.0% of the households at least one member reportedly spent the whole day without food or was hungry but could not get food respectively as summarized in figure 33 below. Figure 33: Effects of the Lockdown on household food security indicators. Comparing the percentage (51.6% and 72.9%) of 47.5 HH member lacked food for a day households that 42.4 reported the 39.6 Skipped a meal ability to afford 60.4 three (3) meals a 12.5 Changed diet 87.5 day for adults and children 17.9 Worried over food insecurity 82.1 respectively vis-àvis the percentage 0 20 40 60 80 100 (82.1%) of No Yes households that was anxious over COVID-19 effect on food security, coupled with 87.5% that changed diet, it is noteworthy that the effect of COVID-19 and its associated restrictions was more speculative than real. This is further confirmed by the small percentage (less than 10%) that mentioned food insecurity as among the effects of COVID 19 and its restrictions on their households. It is therefore apparent that although COVID 19 and its restrictions had affected the supply side factors of food, the situation is notably going back to normal as the households that could afford three (3) or more meals a day were more than those during the lockdown. HH member was hungry but couldn't get food for a day

52.1 47.9

3.4.4 Impact of COVID-19 on jobs and employment The employment sector was/has been among the most hit by the COVID-19 pandemic and its control measures particularly the lockdown, restrictions on the transport system as well as reduced business activity. According to EPRC (2020), the pandemic was projected to cause a 43% reduction in informal employment. Employment in sectors such as transport, non-food retail, and education plus all sectors subject to severe lockdown restrictions was envisaged to be adversely affected. However, whilst several scholars had projected adverse effects of the Page 47 of 118

pandemic on employment, the materialization of these effects would considerably vary across time and space. It was against this backdrop that the analysis of the effect of the pandemic and its associated control measures was at the centre of this study to articulate context-specific issues in Mayuge district as presented below. Descriptive statistics from the caregivers’ interviews show that in 23.4% of the survey households, at least a member lost a job while in the young people’s interview 43.4% indicated that at least a member of the household had lost a job because of COVID-19 and its containment measures. Job loss among household members as revealed in the young people’s interviews was very close to the EPRC (2020) projections of about 43% job reduction due to the COVID 19 pandemic. Besides the job loss, COVID 19 and its containment measures adversely affected the personal working hours of the majority (69.6%) of the respondents in all employment activities. Although some respondents (8.8%) and 21.6% revealed that their working hours had increased during the COVID-19 lockdown period, they were few compared to the vast majority whose working hours had reduced as seen in figure 34 below. Figure 34: COVID-19 effect on personal working hours.

Decreased a lot

42.1

Decreased a little

27.5

Remained the same

21.6

Increased a little

4.4

Increased a lot

4.4 0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

A cross-tabulation analysis of these results shows that the majority of those whose personal working hours were affected were in the business category, while other occupations were not affected adversely as shown in figure 35 below.

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Figure 35: Effect of COVID-19 on working hours by the main source of income. 60 50

Axis Title

40 30 20 10 0

Increased a lot

Farming

Trading (business)

Causal Labourer

Salary Artisan / Remittanc employme vocational es/aid nt

Other

13.3

33.3

20.0

0.0

28.6

Increased a little

45.7

46.7

33.3

40.0

50.0

0.0

Remained the same

23.8

26.7

16.7

40.0

50.0

10.0

57.1

Decreased a little

1.0

13.3

16.7

0.0

14.3

Decreased a lot

9.5

Contrary to other studies (UNDP, 2020), in Mayuge districts and particularly in the study subcounties, personal working hours for a majority (60%) of the respondents that were in salaried employment had reportedly increased while another 40% had remained the same during COVID 19 lockdown. With the imposition of the lockdown on many sectors, working from home as well as working in shifts were introduced and rapidly popularized and this inevitably affected the personal working hours of various workers. 3.4.5 Effect of COVID-19 on domestic social relations and SGBV As Covid-19 spread around the world, countries attempted to control the outbreak by employing lockdowns and quarantine policies. Although stay at home orders was necessary for protecting people from the virus, it unintentionally brought about great dangers and deadly risks like Gender-Based Violence (GBV). For example, the 2020 Uganda Police Crime report indicated domestic violence among the most prevalent crimes reported during the years. Analysis of data from Mayuge Police station revealed an increase of GBV cases between January 2020 and March 20021 as shown in figure 36 below.

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Figure 36: Cases of domestic violence in Mayuge between Jan 2020 and March 2021. There was a skyrocketing of GBV 300 300 cases that were 250 reported during the lockdown period as 200 indicated in figure 150 30. Descriptive statistics from both 100 the caregivers and 50 39 young people’s 36 32 28 27 24 22 20 19 18 18 17 0 interviews indicate that indeed, COVID 19 and its containment measures negatively affected domestic relations breeding a surge of domestic violence cases. Of the 273 caregivers that participated in the survey, 18.3%, 39.6% and 5.9% revealed that at least a member of the household had suffered at least one of the three forms of domestic violence (physical, emotional, and sexual respectively). Responses from young people also revealed that 39.3%, 49.3% and 10.5% had reportedly suffered the physical, emotional, and sexual forms of violence respectively as shown in figure 37. 350

Figure 37: Prevalence of Domestic Violence during the COVID-19 Lockdown. Both caregivers and young 10.5 Sexual Violence people revealed 5.9 that domestic violence under 47.9 Emotional Violence various forms 39.6 had increased during COVID-19 39.3 Physical Violence lockdown. This 18.3 was affirmed by 58.2%, 42.5% 0.0 10.0 20.0 30.0 40.0 50.0 60.0 and 61.9% of the Young People Caregivers caregivers who reported that physical, sexual, and emotional forms of abuse respectively had increased during the period of the lockdown as shown in figure 38.

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Figure 38: Caregiver perceptions on the impact of COVID-19 on SGBV. Decreased a lot Decreased a little Remained the same

Increased a little Increased a lot 0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Emmotional Violence

22.3

39.6

Remained the same 26.4

Sexual Violence

11.4

31.1

40.7

5.1

11.7

Physical Violence

19.0

39.2

29.7

3.7

8.4

Increased a lot Increased a little

Decreased a little 0.7

40.0

45.0

Decreased a lot 11.0

Similar sentiments were also shared by the young people of whom 62.8%, 50% and 76.6% reported that the lockdown had indeed caused an escalation in physical, sexual, and emotional forms of abuse respectively as seen in figure 39 below. Figure 39: Perceptions of young people on the effect of COVID-19 on GBV. Decreased a lot Decreased a little Remained the same Increased a little Increased a lot 0.0

10.0

20.0

30.0

40.0

50.0

70.0

Emmotional Violence

14.1

62.5

Remained the same 13.3

Sexual Violence

14.3

35.7

10.7

25.0

14.3

Phyiscal Violence

11.4

51.4

17.1

14.3

5.7

Increased a lot Increased a little

Decreased a little 8.6

60.0

Decreased a lot 1.6

Analysis of data from the intervention and control sub-counties reveals some slight variations in public perceptions about the prevalence of domestic violence during the lockdown as down in figure 40 below.

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Figure 40: Perceptions on the prevalence of domestic violence by sub-county. 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Mpungwe

Baitambogwe

Physical Violence

Mpungwe

Baitambogwe

Sexual Violence

Mpungwe

Baitambogwe

Emmotional Violence

Increased a lot

63.5

36.5

74.2

25.8

63.9

36.1

Increased a little

49.5

50.5

43.5

56.5

48.1

51.9

Remained the same

54.3

45.7

59.5

40.5

54.2

45.8

Decreased a little

50.0

35.7

64.3

50.0

Decreased a lot

43.5

56.5

43.8

56.3

46.7

53.3

Caregivers who perceived that physical violence during the lockdown had increased a lot were higher in Mpungwe (63.55) than Baitambogwe (36.55). The same observation was made for other forms of violence i.e., sexual, and emotional. Similarly, those who perceived that all forms of domestic violence had declined a lot were also higher in the control sub-county (Baitambogwe) than the intervention (Mpungwe). The Pearson Chi-square result of 0.033 points to a relationship between domestic violence and the respondents’ sub-county. Although the proportion of the caregivers that reported an increase in domestic violence during the COVID 19 lockdown was high, the proportion of the households in the study sample that reported a member having suffered any form of violence was relatively lower. For example, sexual violence was reported in 5.9% of the households that participated in the study while physical and emotional forms of violence in 18.3% and 39.6% respectively. Relatedly, 17 (6.4%) of the 267 young people who participated in the study reported having ever experienced forced sex, and of these, 11 (64.7%) reportedly experienced it in 12 months preceding the study. Of the 11 young people that reported having experienced forced sex in the past 12 months, 6 (54.5%) had experienced it once while 3 (27.2%) and 2 (18.2%) had experienced it twice and thrice respectively. In terms of gender and age, all the 11 young people that had experienced forced sex in the past 12 months were female aged between 12 and 24 years. Only one male person indicated having ever experienced forced sex, but this was not within 12 months preceding the study. In respect to the study sub-counties, 9 (52.9%) of 17 young people that reported having ever experienced forced sex were from Mpungwe while other 8 (47.1%) Baitambogwe. However, of the 11 who had experienced it in the past 12 months, 6 (54.5%) and 5 (43.5%) were Page 52 of 118

Mpungwe and Baitambogwe respectively. Of the 11 that had experienced forced sex, 7 (63.6%) revealed that it was perpetrated by their partners while 2 (18.2%) and 3 (27.3%) by a family friend and another community member, respectively. There is consensus within the available data sources that COVID-19 and its containment measures adversely affected domestic relations and ended up perpetuating domestic violence. As Nabukeera (2021) reported, COVID-19 created danger in the place where many assume it would be safe – within the homevii. This same view was shared by most key informants interviewed in this study. For instance, the District Health Officer had this to say: On SGBV, it is prevalent in the forms of couple separations, beatings especially men beating women because of their masculinity although late reports indicate that there are a few women who beat men, family, and child neglect by men. The Criminal Investigations Officer of Mpungwe Police Post also shared the same opinion on SGBV, mentioning that, …domestic violence especially manifesting in form of husband-and-wife conflicts was very high in this area during the lockdown. What we see is that it was accelerated by alcoholism. These revelations resound the role of power relations in perpetuating domestic violence as well as the disproportionate impact suffered by women. These issues are well established in the literature, with the majority of the perpetrators of violence being men, while women and children suffer the greatest burden. But as observed by the DHO some men also suffer at the hands of abusive women, although the rate of reporting by men tends to below. 3.4.6 Impact on health spending and utilization of SRH services The outbreak of COVID 19 and its associated response measures has caused disruptions in provision and access to health services, including SRH. Descriptive statistics show that during the period between April and June, 93.59% of young people who sought services accessed them. Of these, 56.16% were from Mpungwe, while the rest (43.84%) were from Baitambogwe. The data also reveals that of those who received the services they sought, slightly more than a quarter (27.1%) paid, while the rest (72.74%) did not have to pay. Of these, 11 and 12 representing 47.83% and 52.17% were in Mpungwe and Baitambogwe sub-counties, respectively. Furthermore, among those who paid, the majority (40%) said the cost was high, while 28% reported that it was very high and another 28% considered the cost of services to be low/affordable. Only one young person (4%) reported that the cost of the service was low. Combined, young people who considered the cost paid for SRH services to be high were 68%. Figure 41 below shows young people’s responses on who paid for SRH services.

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Figure 41: Who paid for SRH services accessed by young people. As observed in the figure above, a 6% majority (62%) and 6% indeed more than half of the young people Myself 13% who accessed and Parent/Caregiver utilized services paid Partner/Spouse for themselves, RAHU Peer educator followed by those who 13% 62% Other relative were paid for by their parents/caregivers and those whose partners paid, each representing 13%. Only 6% mentioned that the costs for SRH services were borne by the peer educators. This should not be surprising considering that peer educators are more supposed to play a linkage role to facilities that provide the needed service than personally bearing the cost of the service. Of importance to note is the proportion of young people who reported that SRH services were paid by their caregivers/parents. While this is not necessarily high, it may suggest an emerging attitude shift among parents towards access to and utilization of SRH services by young people. In terms of pricing, the data reveals that the highest price paid to access SRH services was 250,000/= (for maternity and child delivery) while the lowest was 100/= (for HIV/AIDS screening and testing). On the other hand, the overall average price for accessing SRH services was 40,470/=. Only one caregiver out of the total (46) whose young people sought and obtained services mentioned that he/she had to pay UGX 55,000 for their dependent’s pregnancy test, a cost that the caregiver found very high. The rest (45) accounting for 97.83% reported that they did not have to pay anything for young people to access SRH services. Associated costs such as transport costs to access SRH services are also an important consideration and can either facilitate or constrain young people’s access to SRH services. Results reveal that the highest associated cost paid to access SRH services was 60,000/=. On the other hand, a majority (17.86%) of the young people who accessed and obtained SRH services did not have to spend any other money. Combined, young people who spent 1000/= or less were 53.58%, while those who spent 2000/= or less were 64.29%. Despite the relatively low associated costs in accessing sexual and reproductive health services, results seem to indicate that vulnerable categories of young people are more negatively affected than their counterparts without disabilities. In an FGD with caregivers of young people with disabilities, one participant observed that:

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The health centres are very far, and when the disabled person is a young adult and you do not have the means of transport to take them to the health facility, it is quite challenging. They charge 2,000/= to and 2,000/= from which makes 4,000/= for a single person. It can even be more when you are not good at bargaining (FGD, Caregivers of Young people with disabilities (FGD Caregiver of PWD – Buyere; Mpungwe Sub-county) Overall, young people satisfaction with the SRH services was high as shown in figure 42 below. Figure 42: Young people’s satisfaction with SRH services received. As shown in figure 32, half (50%) of all young people Dissatisafied 3.26 who sought and obtained SRH services were satisfied, while 40.22% were very Neither 6.52 satisfied. Combined, the proportion of young people Satisfied 50 that were satisfied and very satisfied with the SRH services received was Very satisfied 40.22 90.22%. Only 9.78% which is slightly less than a tenth was 0 10 20 30 40 50 60 not satisfied with the SRH services. Of these 6.52% were undecided wholesome 3.26% were dissatisfied. None of the young persons interviewed expressed extreme dissatisfaction with the SRH services received. While the percentage of those that were satisfied and very satisfied was slightly higher in Mpungwe than Baitambogwe, the difference is not statistically significant as evidence by the Pearson Chi-square result of 0.357 which is way above the alpha level of 0.05. Overall, the majority (44.44%) of young people who obtained SRH services reported that the expenditure on specific services sought had increased since the imposition of the lockdown, while 11.1% said it has incased a lot. Overall, the proportion of young people who reported that the cost of SRH had increased was a little more than half (55.66%), while those who reported that it had decreased were 22.22%. Regarding the trend in overall expenditure on SRH (including associated costs) since the imposition of the lockdown, a majority (59.21%) of the young people reported that it did not change, while 15.79 and 25% reported that it decreased and increased, respectively.

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3.4.7 Household COVID-19 coping mechanisms The Covid-19 pandemic and implementation measures hurt people’s livelihoods through increased levels of food insecurity, loss of employment, reduced income and expenditure as elaborated in the above sub-sections. In the absence of adequate social protection or social insurance, most households facing income shocks adopted different coping strategies to maintain a certain level of consumption and welfare. These include among others reducing certain types of consumption, selling productive assets, or borrowing at high-interest rates as shown in figure 43 below. Figure 43: Households’ coping mechanism during the lockdown

Skip making a required payment on a loan

34.43

Borrow money you were not certain you could pay back on time

41.39

Deplete your savings

75.09

Sell of other household assets e.g chairs, TV

4.76

Sell of livestock/poultry

48.72

Sell off land

4.03 0

According to the results presented in figure 38 above, the most dominant coping mechanism adopted by households to circumvent the challenges posed by the COVID-19 pandemic and the associated lockdown was the depletion of previously accumulated savings (75.09%), followed by the sale of livestock and other household/domestic animals (48.72%) and borrowing money whose source of repayment was not known (41.39%). In addition, more than a quarter of households/caregivers skipped payment of loans just to make ends meet. Only a paltry 4.03% resorted to selling land. This is probably attributed to the high value placed on land in most communities. However, it could also be that people who would otherwise have purchased land had also postponed expenditure, given the uncertainty presented by the pandemic. Results further reveal that the coping mechanisms to the challenges posed by the pandemic were quite similar across the two sub-counties as 50.3% and 46.9% had to sell off livestock, 73.8 and 76.6% had to deplete their savings, and 47.6% and 34.4% were forced borrow money they were not sure they would pay in Mpungwe and Baitambogwe respectively. A common coping mechanism in times of economic strain is to actively solicit or receive support/aid/charity from others. Indeed, the government through the relevant structures put Page 56 of 118

in place strategies to support vulnerable families, for instance through the distribution of food rations an exercise was undertaken by the UPDF with support from the LDUs. However, as indicated in figure 44 below, the majority (85.05%) of respondents in both sub-counties stated that they did not receive any support/aid to help them make ends meet. Figure 44: Receipt of aid during the lockdown. Overall, food items (35%), cash (23%) and medicine (19%) were the most common forms Food items 16% of aid received by households Cash/money during the period of COVID 19 35% 7% lockdown. The data also shows Medicine that residents in Mpungwe marginally benefited more Clothing 19% than those in Baitambogwe Nonfood items such as when it came to receiving aid 23% soap, salt with 13% of respondents in Mpungwe indicating having received food aid as compared to 7% in Baitambogwe. Furthermore, 8.3% of respondents in Mpungwe received medicine as compared to 3.1% in Baitambogwe. The proportion of residents who received cash aid was almost the same with 6.9% and 7% in Mpungwe and Baitambogwe respectively. About the source of support among households that receive it, relatives and government were the most dominant providers of assistance, accounting for 45.8% and 35.4% respectively as indicated in figure 45 below. Figure 45: Source of support/assistance during the lockdown.

Other

6.25

NGOs

Town or Community leaders

4.17

Neighbors

8.33

Relatives

45.83

Church / mosque

Government or other Politicians

35.42 0

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After relatives and government, the next sources of support to households in the two subcounties during the lockdown were neighbours and town or community leaders. The presence of neighbours and relatives as common sources of support for needy households is evidence of the old age spirit of solidarity/oneness that is still very much prevailing in most communities despite the strong push of modernity and its individualistic tendencies. This is often reflected in slogans such as “muno mukabi” and similar connotations found in other languages. Overall, diversifying sources of income (78.4%), curtailing household expenditure (51.6%) and working longer hours (41.8%) were the main coping mechanisms that were employed by households to minimize the effects of Covid-19 and associated prevention measures as indicated in figure 46 below. Figure 46: Overall coping strategies adopted by households. 90 80

78.39

51.65

41.76

40 30 15.02

8.42

10 0 Diversified income sources

Curtailing HH expenditure

Working for longer hours

Increased borrowing

Other

As indicated above, other coping mechanisms included working longer hours and increased borrowing. It is worth noting however that some coping mechanisms such as increased borrowing could have long-term devastating on the socioeconomic status of livelihoods such as an untenable level of debt, that could make it difficult for households to provide for the basic needs of members as priority is expenditure is channelled to debt repayment. In some instances, loans have also been known to lead to the loss of household assets such as land and other productive assets.

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4.0 Conclusions and Recommendations 4.1

Conclusions

Impact of COVID-19 on young people’s access to and utilization of SRHR services In most of the facilities assesses, the provision of most SRH services went on uninterrupted during the lockdown. This was attributed to routine supply by the district, with support from NGOs, especially regarding mobilization and sensitization. Only three services namely: testing for RTI/STIs, sex and sexuality counselling and IUDs were not available at some facilities during the lockdown, while female condoms were available but at a cost. Contraceptive methods (18.35%), HIV screening and testing (17.9%), SRH counselling and information (10.86%) as well as pregnancy testing (10.11%) were the most needed SRH services by young people during the lockdown. The least needed services were treatment for abortion (1.5%), SGBV counselling and support (1.9%) and postnatal care (3.75%). The need for these services was generally higher among the 15-19 age category. However, the need for maternity and child delivery services as well as postnatal care was highest among young people aged 20-24. On the other hand, young people between 10-14 years were more in in need of SRH counselling and information than any other service. Overall, there is a strong relationship between young people’s age and the need for SRH services, but the difference in the need for the services by sub-county was not striking. The most sought services by young people were antenatal care (93.33%), pregnancy testing (93%), and maternal and child delivery (92.31%), while the least sought were SGBV counselling, SRH counselling and information and testing for other STIs. Overall, a majority (93.6%) of young people who sought services obtained them. The ability to seek for and utilize SRH services was higher among young people in the intervention sub-county (Mpungwe) than the Control (Baitambogwe). However, the Pearson Chi-Square value of 0.044 points to a weak relationship between seeking for and utilizing services on the one hand, and the sub-county on the other. This was further confirmed by the odds ratio of 1.0 which suggests a weak association between the predictor and outcome variables. The predominant source of SRH services for young people was the public health facility, owing to the proximity of the facility and affordability. Failure to seek for and obtain the needed SRH services was attributed to a mix of supply and demand factors including provider characteristics. Specifically, limited awareness on where to seek the service was the overriding inhibitor for the young people to seek the needed SRH services. Other reasons included; transport challenges and stigma associated with some SRH services. On the other hand, unavailability of health workers, inability to afford the cost of the service and unavailability of the services were the major inhibitors to obtaining the needed services. Although the proportion of the young people who had any form of disability was much lower (3.4%), qualitative data indicated that this category experienced disproportional challenges Page 59 of 118

in accessing SRH services during the lockdown. This was mainly due to limitations on transport because of the lockdown and associated ban on public transport as well as long distances to health facilities. Owing to these same challenges, young people in hard-to-reach areas such as islands were even more disadvantaged given that supply of SRH products was limited. Nevertheless, the study did not observe any systemic factors that constrained the provision of SRH services to vulnerable groups of young people at large. Sexual behaviour, access, and utilization of contraceptives Whereas the majority (83%) of the young people reported having engaged in sexual intercourse during the lockdown period, contraceptive use was reported by only 60.8%. The use of contraceptives during the lockdown was however higher (53.9%) in the intervention sub-county than in the control. Despite the slight variations in the observed results, the use of contraceptives cannot be attributed to the peculiar factors in the intervention and control sub-counties as evidenced by the P-value of 0.384. Male condoms and injectables accounting for 55.4% and 26.2% were the most common forms of contraceptives methods used by young people during the lockdown, while the least used were female condoms (1.54%), lactational amenorrhea (1.54%) and implants (3.1%). The predominant use of male condoms may be explained by the extensive availability at most health facilities and in the community at no cost. Indeed, public health facilities were the dominant source of contraceptive for young people during the lockdown. The most dominant reasons for not using contraceptives among young people were partner objection, need for children and fear of side effects. Prevalence of pregnancy among young people during the lockdown was 21%, with the Pearson Chi-Square result of 0.000 suggesting a strong relationship between contraceptive use and pregnancy/conception. Role District and community leaders in the access of SRHR services The majority (72.2%) of the caregivers interviewed did not know any role or assistance rendered by the district and other community leaders in facilitating young people’s access to sexual and reproductive health services during the lockdown. On the other hand, 10.3% and 2.2% respectively reported that local leaders were instrumental in raising awareness about SRH services and issuing movement permits. Only 7.6% of young people interviewed were reported to have obtained SRH information from local leaders/politicians, 5.63% from VHTs and 2.11 from religious leaders. In addition, the district and community leaders were instrumental in eliminating various supply and demand-related factors that affect the provision of SRH services including the supply of the needed SRH products to health facilities in the district. However, local leaders are reported to have experienced challenges in supplying SRH products to facilities in hard-to-reach areas such as islands. Impact of the pandemic on the households of young people 10-24.

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Homegrown food was the main source of food for a majority (85.7%) of the households during the lockdown. The majority of the households could afford two or more meals per day for adults (96.6%) and children (79.1%) at the time of the study, and there were no significant variations between the intervention and control sub-counties as evidenced as a Chi-Square value of 0.88. However, 20.3% and 28.3% of the households in Baitambogwe and Mpungwe sub-counties respectively could not afford a minimum of three (3) meals a day during COVID19 lockdown between March and April 2020. On the other hand, the majority of the households in both sub-counties could afford at least three meals a day. Although weak, there was a relationship between the main source of food and food security during the lockdown, as evidenced by a Pearson Chi-Square result of 0.030. There was no relationship between food security during the lockdown and the sub-county as evidenced by the Chi-square result of 0.127. The results show that COVID-19 and the associated containment measures such as the lockdown had an adverse impact on employment. In 23% of the surveyed households, it was reported that a member lost a job, while a majority (70%) of the caregivers were reported to have experienced a decrease in working hours during the lockdown, the majority of whom were engaged in casual labour (16.7%) and business/trading (13.3%). On the other hand, the largest increases in working hours were reported among caregivers engaged in casual labour (66.6%), farming (65.7%), salaried employment (60%) and business/trading (60%). Households which experienced a decrease in income and an increase in expenditure were 89.4% and 80.22% respectively. Among all the surveyed households, 39.6% had a member who experienced emotional violence during the lockdown, while 18.3% and 5.9% had members who experienced at least one form of physical and sexual violence, respectively. On the other hand, 47.9%, 39.3% and 10.5% of young people reportedly experienced some emotional, physical, and sexual violence respectively during the lockdown. Furthermore, 61.9%, 42.5% and 58.2% of caregivers interviewed were of the view that cases of emotional violence, sexual violence and physical violence respectively had increased in the community during the lockdown. These results were corroborated by data from the police that indicated that in total 300 cases of domestic violence were reported in Mayuge between January 2020 to March 2021, with many other cases thought to not have been reported. The most dominant strategies adopted by families to deal with the challenges posed by COVID-19 and the associated lockdown were depletion of savings (75.1%), sale of livestock/poultry (48.72%) and borrowing money (41.4%). More than a quarter of households (34.43) skipped making payments on their loans. The majority (85.1%) of the surveyed households did not receive any form of aid during the lockdown. Among those that received aid/assistance, food (35%) and cash/money (23%) were the most dominant forms of support to make ends meet. Relatives and government accounting for 45.83% and 35.42% respectively were the most dominant sources of aid for families in need during the lockdown. Page 61 of 118

Overall, a majority (78.4%) of the surveyed households reported having had to diversify their income sources to cope with the challenges of the lockdown, while 51.7% reduced household expenditure and 41.8% increased working hours. An overwhelming (93.59%) number of young people who sought SRH services during the lockdown ultimately accessed them. Of these, slightly more than a quarter (27.1%) paid, while the majority (72.74%) did not incur any cost to access services. Among those who paid, a majority (52.2%) were in Baitambogwe, while the rest were in Mpungwe sub-county. Among those who paid, 68% regarded the cost as high, while 28% found the cost of SRH services to be affordable. A majority (62%) of the young people who accessed and utilized services paid for themselves, while 13% were paid for by their caregivers/parents. More than half (55.7%) of the young people interviewed reported that SRH expenditure had increased since the imposition of the lockdown, while 22.2% did not observe a decrease.

4.2

Recommendations •

•

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ANNEXES ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT Annex 1: Questionnaire for the Young People (10-24 Years) (To be administered to young people both Male & Female aged 10-24 years in sampled households where a caregiver has been interviewed) INTRODUCTION AND CONSENT Good morning/afternoon sir/madam. My name is ________________. I am part of a team that has been contracted by Reach A Hand Uganda (RAHU) an organization working with young people on SRH and other health issues to conduct a study on the impact of COVID-19 pandemic and the associated lockdown measures welfare of young people of families in this community as well as to understand the impact of the pandemic and associated containment measures such as the lockdown on young people’s access to and utilization of SRH services and information. You have been selected randomly to participate in this study by providing information on the questions contained in this questionnaire, and not because anything is known about you or any member of your household. I have already talked to your parent/caregiver and he/she has allowed me to talk with you. However, I also request your permission to discuss these issues with you to learn more about how COVID-19 and the lockdown measures have affected you and your household. If you agree to participate, the discussion/interview will take approximately 30 minutes. At any time during this interview, you are free to withdraw your participation, but we would very much appreciate your full, genuine, and voluntary participation. There are no direct benefits to you or your household for your participation in this study, but the information you provide shall assist RAHU and other partners to design and implement interventions intended to address the effects COVID 19 on the young people and to strengthen the resilience of families and communities affected by COVID-19 and similar crises. The information you provide will remain confidential and shall not be shared with any other person outside this study including your parent/caregiver. In addition, we shall not write down your name or any other information that can identify who you are or where you live. Thank you Do you accept to participate in the study? Yes – Thank the respondent and proceed to administer the interview No – Thank the respondent and proceed to the next sampled household SECTION 1: IDENTIFICATION AND SCREENING QUESTIONS Qn. Question/Filter 100. Date of the interview 101. Time started 102. Interviewer’s name 103. District 104.

Sub-county/Division

105.

Parish

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Responses

Mayuge Mpungwe Baitambogwe Muggi Buyere Butte

Code

1 2 1 2 3

Skip

Igeyero Kasokwe Muggi Buwanuka Buyere Musita Nakitamu 106. Village Butte A Nalwesambula B Butte B Igeyero A Wagona Mukuta Urban 107. Location Rural SECTION 2: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT Qn. Question/Filter Responses Male 201. RECORD SEX OF RESPONDENT Female How old are you in completed years? (Probe: (If respondent does not know their 202. age, ask the year of birth, and use it to ………………………………….. calculate their current age)

203.

What is the highest education level you have attained?

204.

Are you currently enrolled in school?

205.

Why are you not in school?

206.

When did you drop out of school? Was it before or after the lockdown?

207.

What are the reasons you dropped out of school?

208.

What is your religious Affiliation?

209.

Are your biological parents alive?

4 1 2 3 4 5 6 7 8 9 10 11 12 1 2 Code 1 2

Never Attended School Primary Primary Secondary ‘O’ level Secondary ‘A’ level University BTVET Yes No

1 2 3 4 5 6 1 0

Dropped out of school Just completed a level School still closed Other (Specify) Before lockdown After lockdown Lack of fees/tuition Lack of other school necessities Got pregnant/conceived Got married/married Obtained work/employment Other (Specify) Catholic Anglican/Protestant Muslim Born Again/Pentecostal Atheist/Traditionalist Other (specify) Yes, both alive Only father alive Only mother alive

1 2 3 4 1 2 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3

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Skip

1 = 208

1=208 2,3,4=208

4,5 = 211

210.

Do you currently live with any of your biological parents?

211.

What form of disability do you have? (Multiple responses possible, select all mentioned and probe for more)

212.

Do you currently work to earn money?

213.

What different things do you currently do to earn money? (Multiple responses possible, select all mentioned and probe for more)

214.

Did you work to earn money before the lockdown?

215.

What compelled you to start working to earn money? (Multiple responses possible, select all mentioned and probe for more)

216.

How often do you listen to the radio? Would you say? Read out the options

217.

How often do you watch television? Would you say? Read out the options

Both dead/total orphan Don’t know (for both) Yes, with both parents Yes, with father only Yes, with mother only None None Physical Visual/eye related Audio/hearing related Speech related Mental Other (specify) Yes No

4 5 1 2 3 4 1 2 3 4 5 6 7 1 0

Farming Petty trading Business/Commercial Boda Boda/other transport Mining/quarrying Domestic work/chores Salaried job Other (specify) Yes No Need to support my family Need to provide for my basic needs My parents forced me to work Other (Specify) Every day A few times a week At least once a week Not at all Every day A few times a week At least once a week Not at all

1 2 3 4 5 6 7 8 1 0 1 2 3 4

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1 2 3 4 1 2 3 4

0=216

1=216

SECTION 3: SRH RELATED EXPENDITURE DURING THE LOCKDOWN (April to June 2020) I am now going to ask you some questions relating to health-related expenditure during the lockdown. A few may sound personal, but I request you to respond honestly Question/Filter Cod Qn. Responses e At any point during the lockdown (April to June), did you have a need for any of the following health services?

300.

Pregnancy testing HIV/AIDS screening and testing Testing for other STIs/UTIs Antenatal care (ANC) Maternity and child delivery Post-natal care Treatment for abortion Contraceptives / FP methods SRH counselling and information SGBV Counselling and support

1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes

Skip

2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No

For each of the services needed, ask 301.

Did you seek for this service?

302.

What are the reasons you did not seek for this service?

303.

From whom/where did you seek the service?

304.

Did you obtain the service sought?

305.

Did you to pay to obtain this service?

306.

How would you describe the cost/amount charged for the service?

307.

Who paid the money to access this service?

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Yes No Didn’t know where No transport available High transport costs Perceived high cost of service Fear stigma / discrimination Other (Specify) Public health facility Private not for health facility Private for-profit facility Other clinic Pharmacy / drug shop RAHU peer educator / worker Other peer educator / worker Village Health Team (VHT) Other (Specify) Yes No Yes No Very high High Low / Affordable Very low Myself My parents / caregiver My partner / Spouse RAHU peer educator Other peer educator Other CBO / NGO (Specify) My friend Other relative

1 0 1 2 3 4 5 6 1 2 3 4 5 6 7 8 9 1 0 1 0 1 2 3 4 1 2 3 4 5 6 7 8

1=303

1=308 0=309

308.

309. 310. 311.

Other (Specify) Needed service not available Could not afford the cost Health facility closed Health workers not available Other (Specify)

What are the reasons for not obtaining the service? On average, how much did you spend on paying for this service during the lockdown period (April to June)? On average, how much did you incur on other expenses e.g transport to access this service during the lockdown (April to June)? Total cost incurred on accessing this service during the lockdown (April to June)?

312.

How satisfied are you with the service that you received?

313.

What are the reasons for not being satisfied

314.

Overall, how has your expenditure on this service change since the imposition of lockdown?

315.

Overall, how has your expenditure on SRH services changed since the imposition of lockdown?

9 1 2 3 4 5

……………………………… ……………………………… ……………………………… Very satisfied Satisfied Neither Dissatisfied Very dissatisfied High cost of the service Service of poor quality Health workers rude / unfriendly Long waiting time Lack of adequate facilities/equipment Service did not meet my needs Other (Specify) Increased a lot Increased a little Remained the same Decreased a little Decreased a lot Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5 1 2 3 4 5 6 7 8 1 2 3 4 5 1 2 3 4 5

SECTION 4: SEXUAL PRACTICES AND ACCESS TO AND UTILISATION OF FP/SRH/SGBV SERVICES I am going to ask you some questions relating to your sexual practices and access to and utilization of SRH services. A few may sound personal, but I request that you share with me your experience and please, be as truthful as you can. All your responses shall be kept confidential. Qn Question/Filter Responses Code . What is your current marital status? Never Married/not in union 1 (Probe: are you currently married, living Currently married 2 400. as if married, widowed, divorced, or Cohabiting 3 separated?) Separated/divorced 4 Widowed 5 (If not married) Have you ever had Yes 1 401. sexual intercourse? If no response, No 0 assure the respondent of

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1,23=31 4

Skip 2,3=402

0=500

402.

403.

confidentiality and ask the question again (If married/cohabiting or has ever had sexual intercourse) Have you had sexual intercourse during the past 12 months? (Ask only to those that have ever had sex during the last 12 months) During the last 12 months, did you use anything to avoid getting pregnant or impregnating your partner? What did you use to avoid getting pregnant or impregnating your partner? (Multiple responses possible, select all mentioned and probe for more)

404.

From where did you obtain these method/methods? (Multiple responses possible, select all mentioned and probe for more) 405.

What are the reasons for using this/these methods? (Multiple responses possible, select all mentioned and probe for more) 406.

407.

408.

Are you satisfied with the method you/your partner used? Why are you not satisfied with the method you/your partner used? (Multiple responses possible, select all mentioned and probe for more)

Yes No

1 0

Yes No

1 0

Pills Injectables Emergency contraception Male condoms Female condoms IUD Implants Moon beads Lactational amenorrhea Periodic abstinence Withdrawal Other (specify) Public health facility Private not for health facility Private for-profit facility Pharmacy/drug shop/clinic TBA/Herbalist RAHU peer educator / worker Other peer educator/worker Village health team (VHT) NGO/CBO worker (Specify) Don’t know Other (Specify) Prevents STIs & HIV Cheaper Lasts longer Always available Easy to get Easy to use No side effects More effective Recommended by doctor Recommended by a friend Partner preference Other (specify) Yes No Method is not very effective Difficult to use/administer Has side effects Cost/expensive

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1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11 12 1 0 1 2 3 4 5

0=500 0=409

1=500

What are the reasons that you did not use any method to avoid getting pregnant/your spouse getting pregnant? (Multiple responses possible, select all mentioned and probe for more) 409.

410.

Did you conceive or make some one pregnant during the past 12 months?

My partner doesn’t support/like it Fear about fertility / infertility Other (specify) No need e.g married Wanted to have children Fear of side-effects Facility hard to access Preferred method not available Health workers not available to provide No money to buy Parents/caregivers objected Partner objected to use Other (specify) Yes No

6 7 1 2 3 4 5 6 7 8 9 10 1 0

SECTION 5: EXPOSURE TO INFORMATION AND COMMUNICATION ABOUT SRH SERVICES Qn . 500.

501.

502.

Question/Filter

Responses

In the past 12 months, have you seen or heard any communication / messages / activities about SRH? Where/from whom did you hear this communication/messages about SRH in the past 12 months? (Multiple responses possible, select all mentioned and probe for more)

Through what channel / means did you get the information / communication / message? (Multiple responses possible, select all mentioned and probe for more)

What was this message / information / communication about? (Multiple responses possible, select all mentioned and probe for more) 503.

Yes No Health worker / Counsellor RAHU peer educator/worker Other peer educator / worker Other NGO / CBO (Specify) Village Health Team (VHT) Community group/club Religious leader Local leader/politician Others (Specify) Phone Television Radio Mobile megaphone Static megaphone Poster/Signposts Drama / video Other (Specify) How to prevent/avoid pregnancy HIV counselling and testing How to prevent other STIs Post abortion care/counseling How to make health SRH choices How to keep good menstrual health On gender-based violence/SGBV

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Code 1 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 9 10

Skip 0=504

Other (Specify) 504.

In the past 12 months, have you been visited by a peer educator / worker to talk about SRH services and information? What SRH information was shared by the peer leader/educator during the visit? (Multiple responses possible, select all mentioned and probe for more)

1 0 How to prevent / avoid pregnancy HIV counselling and testing How to prevent other STIs Post abortion care/counseling How to make health SRH choices How to keep good menstrual health On gender-based violence / SGBV Other (Specify) Yes No

1 2 3 4 5 6 7 8 9 10

How to prevent/avoid pregnancy HIV counselling and testing How to prevent other STIs Post abortion care/counseling How to make health SRH 507. choices How to keep good menstrual health On gender-based violence / SGBV Other (Specify) How useful was the information Very useful 508. shared/received during these Somewhat useful meetings/activities/engagements? Not useful SECTION 6: IMPACT OF COVID-19 ON HOUSEHOLDS OF YOUNG PEOPLE

1 2 3 4 5 6 7 8 9 10

505.

506.

600.

601.

In the past 12 months, have you attended any peer group activity on youth friendly SRH? What SRH information was shared during this activity / meeting / engagement? (Multiple responses possible, select all mentioned and probe for more)

1 0

1 2 3

Did the COVID-19 pandemic and associated containment measures such as lockdown, curfews, travel restrictions, restrictions in gatherings etc. make it difficult for you to? a. Access SRHR services and information 1. Yes 2. No Don’t know b. Pay for SRHR services and information 1. Yes 2. No Don’t know c. Access other needed health services 1. Yes 2. No Don’t know d. Pay for other needed health services 1. Yes 2. No Don’t know e. Get enough food i.e. at least three meals per day 1. Yes 2. No Don’t know Did the COVID-19 pandemic and associated containment measures such as lockdown, curfews, travel restrictions, restrictions in gatherings etc. make it difficult for your household to a. Provide enough food i.e., at least three meals 1. Yes 2. No Don’t know per day b. Pay for water and other utilities 1. Yes 2. No Don’t know c. Access markets / shops to buy basic needs 1. Yes 2. No Don’t know d. Access markets to sell items e.g farm produce 1. Yes 2. No Don’t know e. Pay for rent / accommodation 1. Yes 2. No Don’t know f. Care for sick family members 1. Yes 2. No Don’t know

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0=506

0=600

602.

603.

604. 605.

g. Support needy family members or relative 1. Yes 2. No Don’t know Did the COVID-19 pandemic and associated containment measures such as lockdown, curfews, travel restrictions, restrictions in gatherings etc. cause the following to happen to you or any member of your household? 1. Yes 2. No Don’t know Lose his or her job 1. Yes 2. No Don’t know Reduce working hours 1. Yes 2. No Don’t know Deplete savings 1. Yes 2. No Don’t know Earn less money than before money 1. Yes 2. No Don’t know Work in an unusual job 1. Yes 2. No Don’t know Close a business 1. Yes 2. No Don’t know PREVALENCE OF SGBV DURING THE LOCKDOWN During the lockdown, how often did you witness the following happen to you or any member of your household Physical violence Often/Frequently 1 (It can be any of these actions: Push you, shake you, or Sometimes/Occasionall 2 throw something at you, twist your arm or pull your hair, y 3 punch / slap you with something that could hurt you, Seldom/Rarely 4 kick you, drag you, or beat you up or threaten or attack Never/Not at all you with a weapon) Increased a lot 1 Increased a little 2 Compared to before the lockdown, would you say this Remained the same 3 has? (Read out options) Decreased a little 4 Decreased a lot 5 Emotional violence Often/Frequently 1 (It can be in any of these actions: Say or do something to Sometimes/Occasionall 2 humiliate you in front of others, threaten to hurt or harm y 3 you or someone you care about, insult you or make you Seldom/Rarely 4 feel bad about yourself) Never/Not at all Increased a lot 1 Increased a little 2 Compared to before the lockdown, would you say this Remained the same 3 has? (Read out options) Decreased a little 4 Decreased a lot 5 Sexual violence Often/Frequently 1 (It can be any of these actions: Physically force you to Sometimes/Occasionall 2 have sexual intercourse when you did not want to, seduce y 3 you with money / other benefits to perform sexual acts Seldom/Rarely 4 you did not want to) Never/Not at all Increased a lot 1 Increased a little 2 Compared to before the lockdown, would you say this Remained the same 3 has? (Read out options) Decreased a little 4 Decreased a lot 5 Have you ever experienced any form of Yes 1 forced sexual intercourse (i.e., someone having sex with you against your will) in No 0 your community i.e. home or school? Did you experience any form of forced Yes 1 sexual intercourse in the last 12 months? No 0

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0=END

606.

How many times did you experience any form of forced sexual intercourse in the last 12 months

Who forced you into sex? (Multiple responses possible, select all mentioned and probe for more) 607.

608.

When you were forced to have sex against your will, did you or a family member report the case to any authority? To whom was the case reported? (Multiple responses possible, select all mentioned and probe for more)

One Two Three More than three My partner My parent/guardian Brother/stepbrother Other relative Family friend Teacher My employer Other community member Complete/Total stranger Other (Specify) Yes No

609.

What action was taken when you reported the case? 610.

611.

When you experienced forced sexual intercourse, did you receive any counseling/talk to any professional? From whom did you receive any counseling/talk to any professional? (Multiple responses possible, select all mentioned and probe for more)

612.

613.

How useful was the counseling/help that received?

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1 2 3 4 1 2 3 4 5 6 7 8 9 10 1 0

Parent/Guardian Teacher Health worker RAHU Peer educator / worker Other peer educator / worker Police officer Religious leader Politician/local leader Other (specify) No action taken Offender arrested Offender arrested and prosecuted Offender arrested, tried and sentenced Yes No

1 2 3 4 5 6 7 8 9

Parent/Guardian Teacher Health worker RAHU Peer educator / worker Other peer educator / worker Police officer Religious leader Politician/local leader Other (specify) Very useful Somewhat useful Not useful

1 2 3 4 5 6 7 8 9

0=611

1 2 3 4 1 0

1 2 3

0=614

If never reported the abuse, what are the reasons you did not report? 614.

Feared retribution Was threatened Did not know where to report Did not trust anyone No action would be taken Fear of stigma/discrimination Family negotiated with offender Other (specify) END

Thank the respondent for participating in the study

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1 2 3 4 5 6 7 8

ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT Annex 2: Questionnaire for Caregivers of Young People (10-24 Years) (To be administered to Parents/Caregivers of young people aged 10-24 years in sampled households) INTRODUCTION AND CONSENT Good morning/afternoon sir/madam. My name is ________________. I am part of a team that has been contracted by Reach A Hand Uganda to conduct a study on the impact of COVID-19 pandemic and the associated lockdown measures welfare of young people of families in this community as well as to understand the impact of the pandemic and associated containment measures such as the lockdown on young people’s access to and utilization of SRH services and information. You have been selected randomly to participate in this study by providing information on the questions contained in this questionnaire, and not because anything is known about you or any member of your household. However, participation in the study is voluntary and no personal benefits shall accrue to your participation. The information you provide will remain confidential and shall not be shared with any other person outside this study. In addition, we shall not write down your name or any information that can identify who you are or where you live. I therefore request your permission to discuss these issues with you. The discussion/interview takes approximately 30 minutes. At any time during this interview, you are free to withdraw your participation, but we would very much appreciate your full, genuine, and voluntary participation. There are no direct benefits to you or your household for your participation in this study, but the information you provide shall assist RAHU and other partners to design and implement interventions intended to address the effects COVID 19 on the young people and to strengthen the resilience of families and communities affected by COVID-19 and similar crises. Later, I will request to conduct a separate interview with a young person male or female in your household aged 10-24 to also find out how the COVID-19 pandemic and the lockdown measures have affected various aspects of their life. The interview with the selected young person shall be conducted in privacy to allow them easily to express themselves. Thank you Do you accept to participate in the study? Yes – Thank the respondent and proceed to administer the interview No – Thank the respondent and proceed to the next sampled household SECTION 1: IDENTIFICATION AND SCREENING QUESTIONS Qn.

Question/Filter

100.

Date of the interview

101.

Time started

102.

Interviewer’s name

103.

District

104.

Sub-county/Division

105.

Parish

Code

Responses

Mayuge Mpungwe 1 Baitambogwe 2 Muggi 1

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Buyere 2 Butte 3 Igeyero 4

106.

Village

107.

Location

Kasokwe Muggi Buwanuka Buyere Musita Nakitamu Butte A Nalwesambula B Butte B Igeyero A Wagona Mukuta

1 2 3 4 5 6 7 8 9 10 11 12

Urban 1 Rural 2

SECTION 2: SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENT Qn.

Responses Code

Question/Filter

Male 1 Female 2

200.

Gender of the respondent

201.

How old are you in complete years?

…………………………………..

What is the highest education level you have attained?

Never Attended School Primary Primary Secondary ‘O’ level Secondary ‘A’ level University BTVET

1 2 3 4 5 6

Never Married/not in union Married monogamous Married polygamous Cohabiting Separated/divorced Widowed

1 2 3 3 4 5

Farming Trading (business) Causal Labourer Salary employment Artisan / vocational Remittances/aid Others specify ……………….

1 2 3 4 5 6 7

202.

203.

What is your current marital status? (Probe: are you currently married, living as if married, widowed, divorced, or separated?)

204.

What is your MAIN source of income that supports your livelihood?

205.

Are you the head of this household?

206.

Household headship / type

Yes 1 No 0 Male headed 1 Female headed 2

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(Use the information above to complete this question) 207.

208.

209.

210.

Child headed 3 Spouse Mother / Father Son/daughter Other relative

(If not Household Head), What is your relationship with the HH?

(If not Household Head), How old is the HH in complete years?

…………………………………..

(If not Household Head), What is the

Never Attended School Primary Primary Secondary ‘O’ level Secondary ‘A’ level University BTVET

1 2 3 4 5 6

(If not Household Head), What is the

Farming Trading (business) Causal Labourer Salary employment Artisan / vocational Remittances/aid Others specify ……………….

1 2 3 4 5 6 7

highest education level of the HH?

MAIN source of income of the HH?

In total, how many members does this household have?

…………………………………..

How many are below 18 years?

…………………………………..

How many are aged 60 and above?

…………………………………..

How many are in school?

…………………………………..

How many have a disability?

…………………………………..

How many are employed / doing something to earn money?

…………………………………..

How many have chronic illnesses such as cancer, heart disease, HIV etc

…………………………………..

211.

1 2 3 4

SECTION 3: HOUSEHOLD SOCIO-ECONOMIC STATUS Qn.

Responses Code

Question/Filter

300.

Who is the primary provider of your household basic needs?

301.

What is the main source of income for this household?

Husband alone Wife alone Both husband and wife Parents Other (Specify)……………………..

1 2 3 4 5

Crop farming Cattle keeping Fishing Salary/wage

1 2 3 4

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302.

303.

Business Boda Boda/other transport Remittances/Aid Other (Specify)……………………..

5 6 7 8

What is your estimated average household income per month (for all members of the household, ask for income from various sources including salaries, IGAs / Businesses, remittances etc)?

< 50,000 50,000-150,000 150,001-250,000 250,001-350,000 350,001-450,000 450,001-550,000 550,001-1,000,000 >1,000,000

1 2 3 4 5 6 7 8

What is your estimated average household expenditure per month on all items?

< 50,000 50,000-150,000 150,001-250,000 250,001-350,000 350,001-450,000 450,001-550,000 550,001-1,000,000 >1,000,000

1 2 3 4 5 6 7 8

Home grown Market Exchanging work Relief aid Help from neighbours Other(s) specify………………….

1 2 3 4 5 6

How many meals do adult members of the household have in a day?

One Two Three More than 3

1 2 3 4

How many meals do children in this household have in a day?

One Two Three More than 3

1 2 3 4

What is the main source of food for the household? 304.

305.

306.

307. a

Does your household own any of the following?

Yes 1 No 0

Land for cultivation

Yes 1 No 0

Land acreage owned by household?

< an acre 1-2 acres 3-5 acres More than 5 acres

1 2 3 4

What is the ownership of this land?

Man/husband alone Wife / woman alone Both husband and wife Owned by the clan

1 2 3 4

aii

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0 = 307b

Yes 1 No 0

aiv

Do all adult members of the household have access to this land in case they want to use it? Is the land adequate for all your agricultural activities?

Livestock such as goats, cows, sheep, pigs etc?

Yes 1 No 0

Poultry such as chicken, ducks, guinea fowls, turkeys etc

Yes 1 No 0

Radio set

Yes 1 No 0

Television set

Yes 1 No 0

Mobile phone

Yes 1 No 0

Bicycle

Yes 1 No 0

Motorcycle / Boda boda

Yes 1 No 0

Car / vehicle

Yes 1 No 0

aiii

d e f g h i

Qn.

Yes 1 No 0

SECTION 4: ACCESS TO SEXUAL & REPRODUCTIVE HEALTH SERVICES FOR THE YOUNG PEOPLE Question/Filter Responses Code Skip

400.

Do you think it is okay for parents to discuss SRH issues such as pregnancy, menstrual health, contraceptives, abortion, HIV, STIs etc with their children/young people?

401.

At what age do you think it is okay for parents to discuss SRH issues with their children and young people?

Below 10 years 11 – 14 years 15 – 17 years 18 years and above

1 2 3 4

Who do you think should discuss SRH issues with children and young people?

Parents/caregivers Health facility/health worker Auntie / Uncle Religious leader Teacher Politician VHT Peer leader Other (Specify)

1 2 3 4 5 6 7 8 9

402.

Yes 1 No 0

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0 = 403

403. 404.

405.

406.

Do you feel free to discuss SRH issues with children and young people in your household/under you care? Have you ever discussed SRH issues with your children and young people in under your care? During the lockdown (last 12 months), did you or your partner/spouse discuss SRH issues such as pregnancy, menstrual health, contraceptives, abortion, HIV, STIs etc with children and young people under your care?

Yes 1 No 0

0 = 500

Yes 1 No 0

0 = 408

Myself / spouse 1 The young people 2 Other (Specify) 3

Who initiated this discussion / conversation?

407.

What SRH issues did you discuss with children and young people under your care?

408.

Do you know where young people can access SRH services and information in this community

409.

Mention the place where young people can access SRH services and information in this community

410.

During the lockdown (last 12 months), did you or your partner/spouse encourage young people in this household to seek SRH services and information?

411.

Yes 1 No 0

From whom/where did you or your partner/spouse encourage young people in this household to seek SRH services and information?

How to prevent/avoid pregnancy How to prevent HIV/AIDS How to prevent other STIs How to make health SRH choices How to keep good menstrual health On gender-based violence/SGBV Other (Specify)

1 2 3 4 5 6 7

Yes 1 No 0 Public health facility Private not for health facility Private for-profit facility Pharmacy/drug shop/clinic TBA/Herbalist RAHU peer educator / worker Other peer educator/worker Village health team (VHT) NGO/CBO worker (Specify) Don’t know Other (Specify)

1 2 3 4 5 6 7 8 9 10 11

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0 = 410

1 2 3 4 5 6 7 8 9 10 11

0 = 420

412.

413.

414.

415.

416.

Yes 1 No 2 Don’t know 3

Did young people in this household obtain the SRH services and information they were seeking?

What SRH services and information did they receive?

Did you have to pay any money for the SRH services received by young people in this household? On average, how much did you spend on SRH services for young people in this household during the lockdown period (April to June)? How would you describe the expenditure on SRH services for young people in this household during the lockdown period (April to June)??

417.

Overall, how has your expenditure on SRH services for young people in this household changed since the imposition of lockdown?

418.

How useful have been the SRH services and information provided to young people during the lockdown / last 12 months?

419.

Contraceptives / FP How to prevent/avoid pregnancy How to prevent HIV/AIDS How to prevent other STIs How to make health SRH choices How to keep good menstrual health On gender-based violence/SGBV Other (Specify)

Please mention the reasons why your children/ young people did not receive the services / information sought?

420.

Why did you not talk to your children and young people about or encourage them to seek SRH services and information during the lockdown?

421.

How did the district and community leaders assist young people in this area to access SRHR services during the lockdown?

1 2 3 4 5 6 7 8

Yes 1 No 0 ……………………………… Very high High Low / Affordable Very low Increased a lot Increased a little Remained the same Decreased a little Decreased a lot Very useful Somewhat useful Not useful

1 2 3 4 1 2 3 4 5 1 2 3

No transport to health facility No money to pay for services Health facility closed Health workers not available Don’t know Other (Specify)

1 2 3 4 5 6

Didn’t have time Don’t free to talk to them Can discover on their own They are still young It’s not culturally appropriate They are not free with/don’t trust me I am not informed about SRH issues Other (specify) No assistance at all Issuing of movement permits Supply of SRH products Provided awareness & sensitization SRHR case management & referrals Don’t know

1 2 3 4 5 6 7 8 1 2 3 4 5 6

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2,3 = 419

0 = 418

Others (Specify) 7

SECTION 5: IMPACT OF COVID 19 AND LOCKDOWN ON YOUNG PEOPLE & THEIR HOUSEHOLDS Since onset of COVID-19 in the Increased a lot 1 country and the introduction of Increased a little 2 500. restrictive measures, would you say Remained the same 3 that your personal working hours in Decreased a little 4 all employment activities have… Decreased a lot 5

501.

Since onset of COVID-19 in the country and the introduction of restrictive measures, would you say that your household’s income from all sources has…

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

502.

How has your household income changed since the relaxation of lockdown measures? Would you say it has…

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

503.

Overall, did your household spend more or less in during the lockdown (last 12 months) compared to other normal years?

Much more A little more The same A little less Much less

1 2 3 4 5

504.

On which items did you spend most

Food items Medical care Education Clothing / footwear Utilities e.g power and water Entertainment/leisure Aid/help to others Others (specify)

1 2 3 4 5 6 7 8

505.

How have your household expenditure changed since the relaxation of lockdown measures? Would you say it has…

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

506.

Since onset of COVID-19 in the country and the introduction of restrictive measures, would you say the prices of food you buy have increased or decreased?

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot Don’t know/ don’t buy food

1 2 3 4 5 6

507.

Since onset of COVID-19 in the country and the introduction of restrictive measures, do you think the living conditions of your household

Much better Somewhat better Same Worse

1 2 3 4

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3,4,5 = 504

508.

509.

are worse, the same, or better than the economic conditions of other individuals in this town? Since onset of COVID-19 in the country and the introduction of restrictive measures, do you think the living conditions of other people in your community are worse, the same, or better than the economic conditions of other individuals in this town?

Did the COVID-19 pandemic and associated containment measures such as lockdown, curfews, travel restrictions, restrictions in gatherings etc. make it difficult for your household to?

Much worse 5

Much better Somewhat better Same Worse Much worse Don’t know

1 2 3 4 5 6

Afford/get enough food to eat i.e., at least three meals per day Pay for water and other utilities Access markets/shops to buy basic needs Access markets to sell items e.g farm produce, livestock etc. Pay for rent / accommodation Care for sick family members Provide for / support needy family members or relative Access health care services Pay for health care of members Pay for home schooling of school going children

1 2 3 4 5 6 7 8 9

FOOD SECURITY During the lockdown… 510. 511. 512.

513.

514.

515.

Were you worried you would run out of food because of a lack of money or other resources? Did your household have to change the diet because of a lack of money or other resources? Did your household have to skip a meal because there was not enough money or other resources to get food? Did you or any member of your household go without eating for a whole day because of a lack of money or other resources? Were you hungry but did not eat because there was not enough money or other resources for food? Overall, how was your household affected by COVID 19 response measures?

Yes 1 No 0 Yes 1 No 0 Yes 1 No 0 Yes 1 No 0 Yes 1 No 0 Never affected Income loss/reduced Increase in expenditure Some HH members lost jobs Reduction in working hours Accelerated domestic violence Moral decline in children Failure to access critical services

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1 2 3 4 5 6 7 8

Failure to care for needy members 9 Food insecurity 10 Other(s) specify…………………. 11

516.

Since onset of COVID-19 in the country and the introduction of restrictive measures, would you say cases of physical violence in families in this community have?

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

517.

Since onset of COVID-19 in the country and the introduction of restrictive measures, would you say cases of sexual violence in families in this community have?

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

518.

Since onset of COVID-19 in the country and the introduction of restrictive measures, would you say cases of emotional violence in families in this community have?

Increased a lot Increased a little Remained the same Decreased a little Decreased a lot

1 2 3 4 5

519.

Since onset of COVID-19 in the country and the introduction of restrictive measures, have any of the following happened to you or any member of your household?

Physical violence 1 Emotional/psychological violence 2 Sexual violence 3

COPING MECHANISMS

520.

521.

522.

523.

Sell off land Sell of livestock/poultry Sell of other household assets e.g chairs, TV Deplete your savings Borrow money you were not certain you could pay back on time Skip making a required payment on a loan

1 2 3

Since onset of COVID-19 in the country and the introduction of restrictive measures, have you received any of the following in form of support/aid to make ends meet?

Food items Cash/money Medicine Clothing Nonfood items such as soap, salt

1 2 3 4 5

From whom did you receive this support/help/assistance?

Government or other Politicians Church / mosque Relatives Neighbors Town or Community leaders NGOs Other (Specify)

1 2 3 4 5 6 7

Diversified income sources Curtailing HH expenditure Increased borrowing Working for longer hours

1 2 3 4

Since onset of COVID-19 in the country and the introduction of restrictive measures, have you or someone in your household been forced to do any of the following to pay for food, healthcare, or other expenses?

Overall, how is your household coping with the COVID 19 effects?

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3 4 5

Other(s) specify………………… 5

Thank the respondent for agreeing to participate and request to conduct the interview with a young person in the household

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ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

Annex 3: FGD Guide for Young People (Male and Female) Aged 10-24 years (Record District, Sub-county, Village, Age and Sex of Participants. Also record moderator, notetaker, time started, time finished and venue of the interview/discussion)

1. What are the major SRH issues/concerns of young people in this community? Probe about teenage pregnancies, abortions, HIV/AIDS, STIs etc.) 2. How widespread are these issues in this community? 3. How important is it to provide young people like you with SRH information and services? 4. Where do young people in this community usually access SRH services and information? (Probe about the availability of youth friendly services (youth centres/corners)

Provision of SRH services at during the lockdown 5. What were the major SRH issues/concerns of young people in this community during the lockdown? Probe about teenage/unplanned pregnancies, abortions, HIV/AIDS, STIs, Defilements and other SGBV issues 6. What different interventions/measures/channels were put in place to enable young people in this community to access and utilize the needed SRH services and information during the lockdown? Probe for ● Health facility/youth centre/corner talks ● Community outreaches/discussion ● Community drives / megaphone ● Home visits/Door to door ● Radio talk/TV shows etc. 7. Please comment on the effectiveness of each of the various measures put in place to enable young people in this community to access and utilize the needed SRH services

SRH service provision at the health facility during the lockdown 8. What different SHR services were available to young people like you at the health facility during the lockdown? Probe about ● Family planning services (ask about specific products/methods provided) ● SRH information and education ● HIV/AIDS Counselling and Testing ● Screening for other STIs ● SGBV information and counseling ● Menstrual health and sexuality education ● Cervical cancer screening Page 85 of 118

9. In the case of SRH information and education, please ask about ● The different SRH issues discussed ● Relevance of topics discussed/presented to needs of young people ● The different methods/approaches used e.g group discussion, Q&A sessions, drama, videos/television ● Relevance of method/approaches used to convey the message 10. Please comment on the quality of SRH service provision to young people at the health facility during the lockdown. Probe about: ● Adequacy of facilities e.g space ● Adequacy of equipment and tools ● Friendliness of staff/providers ● Level of privacy in service provision ● Affordability/cost of services 11. Please comment on the level of young people’s uptake and utilization of these services during the lockdown (Probe about uptake for males and females, People with Disabilities, People Living with HIV/AIDS, those from remote areas, teenage mothers, out of school youths and other key populations etc.) 12. What were the major challenges/barriers to young people’s access and utilization of SRH services and information during the lockdown? Probe about: Cost/charges of services, Transport, curfews, restrictions to gatherings, product stockouts, lack of staff etc. 13. What suggestions recommendations would you like to make to improve SRH services for young people in this community?

Impact of COVID-19 on households of young people in the community 14. How has/did the COVID-19 pandemic affect the socioeconomic status/livelihoods of your families/households in this community? Probe about ● Ease/difficulty in providing for basic needs such as food and clothing. ● Ease or difficulty in providing for health ● Ease or difficulty in paying for other utilities such as electricity and water ● Ease or difficulty in providing for home schooling materials ● Loss of jobs/employment ● Prevalence of domestic violence/gender-based violence 15. Has the situation changed/transformed since the lifting of lockdown measures? If yes, how has it changed

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ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

Annex 4: FGD Guide for Caregivers of Young People (Male and Female) 1. What are the major SRH issues/concerns of young people in this community? Probe about teenage pregnancies, abortions, HIV/AIDS, STIs etc.) 2. How widespread are these issues in this community? 3. How important is it to provide young people like you with SRH information and services? 4. Where do young people in this community usually access SRH services and information? (Probe about the availability of youth friendly services (youth centres/corners) 5. Do parents talk to young people about sexual reproductive health (SRH) issues? ● If yes, what are the reasons? ● What issues do they talk about? ● If not, what are the reasons? 6. Do young people talk to their parents/caregivers about SRH issues? ● If yes, what are the reasons? ● What issues do they talk about? ● If not, what are the reasons? 7. Do you think adolescents should access information on issues like sex, STIs and condoms? 8. What are the reasons they should/should not access information on SRH issues? 9. Do you think adolescents should access SRH services such as services such as condoms, STI testing, HIV testing, contraceptives, etc. 10. What are the reasons they should/should not access SRH services?

Provision of SRH services at during the lockdown 11. What were the major SRH issues/concerns of young people in this community during the lockdown? Probe about teenage/unplanned pregnancies, abortions, HIV/AIDS, STIs, Defilements and other SGBV issues 12. How widespread were these different issues during the lockdown? Probe on incidents occurred, those reported, those unreported etc. 13. Did you and other parents like you do anything to address the various SRH issues/concerns of young people during the lockdown? ● If yes, what did you do? Probe about initiating parent-child talks, promoting talks with health workers, religious leaders, peer educator, undertaking HIV/STI tests, conducting pregnancy tests etc. ● Probe: How helpful/important were these different initiatives ● How did those discussions influence the way you relate with or handle your adolescent children? Page 87 of 118

● Probe: If not, what are the reasons you didn’t do anything? 14. Did you participate in any meetings / discussions about the SRH of young people in this community during the lockdown? ● If yes, who organized the meeting/discussion? ● What issues/topics discussed in the meeting? ● How relevant were these issues discussed in the meeting? ● How helpful/important were the issues discussed in the meeting? ● How did those discussions influence the way you relate with or handle your adolescent children? 15. Did your children or other young people in this community participate in any meetings / discussions about the SRH of young during the lockdown? ● If yes, who organized the meeting/discussion? ● What issues/topics discussed in the meeting? ● How relevant were these issues discussed in the meeting? ● How helpful/important were the issues discussed in the meeting? ● How did those discussions influence/affect/change the way your adolescent children relate with you? 16. What were the major challenges/barriers to young people’s access and utilization of SRH services and information during the lockdown? Probe about: Cost/charges of services, Transport, curfews, restrictions to gatherings, product stockouts, lack of staff at health facilities, negative attitudes towards SRH by the community/parents etc. 17. What more could have been done to better facilitate you and others like you to provide SRH services to young people during the lockdown? 18. Overall, what suggestions recommendations would you like to make to improve SRH services for young people in this community? 19. How do you support your adolescent children in their health and day to day lives?

Impact of COVID-19 on households of young people in the community 20. How has/did the COVID-19 pandemic affect the socioeconomic status/livelihoods of your families/households in this community? Probe about ● Ease/difficulty in providing for basic needs such as food and clothing. ● Ease or difficulty in providing for health ● Ease or difficulty in paying for other utilities such as electricity and water ● Ease or difficulty in providing for home schooling materials ● Loss of jobs/employment ● Prevalence of domestic violence/gender-based violence 21. Has the situation changed/transformed since the lifting of lockdown measures? If yes, how has it changed ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

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Annex 5: Interview Guide for District/Sub-county Health Officials and Political Leaders Record Position, Age, Sex and Telephone contact of Respondent

1. What are the major issues/concerns about the health of young people in this community today? (probe about teenage pregnancy, early marriage, HIV, STIs, SGBV etc.) 2. Where do young people/adolescents in this district/subcounty/community get information and services about sexual reproductive health issues? 3. To what extent is SRH for young people (aged 10-24) a priority in this district? (Probe about planning, budgeting, and human resourcing for SRH needs of young people) 4. What interventions have been implemented in the last 3 years in your district to improve the SRH lives of young people (10-24 years)? Probe: Who are the major actors in the SRH field in this district/area?

Provision of SRH services to young people at during the lockdown 5. What were the major SRH issues/concerns of young people in this community during the lockdown? Probe about teenage/unplanned pregnancies, abortions, HIV/AIDS, STIs, Defilement and other SGBV issues 6. What different interventions/measures were put in place in this district/sub-county to enable young people in this community to access the needed SRH services and information during the lockdown? ● Probe for the coverage/reach of these interventions ● What proportion/number of health facilities in this district/subcounty were involved in the provision of SRH services to young people during the lockdown? 7. Please comment on the effectiveness of the various measures (mentioned above) put in place to enable young people in this community to access and utilize the needed SRH services 8. What specific role did the district/sub-county play in the provision of SRH information and services to young people during the lockdown? ● Probe for roles played in planning, in supervision, and in financing 9. What other actors supported the provision of SRH services and information to young people during the lockdown? What did they do? 10. Please comment on young people’s utilization of SRH during the lockdown 11. What were the major challenges/barriers to young people’s access and utilization of SRH services and information during the lockdown? Probe about Cost/charges of services etc.

12. What more could have been done to improve young people’s access to and utilization of SRH services during the lockdown? 13. What more could have been done to improve young people’s access to and utilization of SRH services during the lockdown?

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ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT Annex 6: Interview Guide for Peer Educators (Record Position, Age, Sex, and telephone contact of Respondent)

1. What are the major SRH issues/concerns of young people in this community? Probe about teenage pregnancies, abortions, HIV/AIDS, STIs, SGBV etc.) 2. How widespread are these issues in this community? 3. Of what importance is it to provide young people with SRH information and services? 4. Where do young people in this community usually access SRH services and information? (Probe about the availability of youth friendly services (youth centres/corners)

Provision of SRH services to young people during the lockdown 5. What were the major SRH issues/concerns of young people in this community during the lockdown? Probe about teenage/unplanned pregnancies, abortions, HIV/AIDS, STIs, Defilements and other SGBV issues 6. What different interventions/measures/channels were put in place in this community to enable young people to access and utilize the needed SRH services and information during the lockdown? Probe for ● Health facility/youth centre/corner talks – How often ● Community outreaches/discussions – How often ● Community drives / megaphones – How often ● Home visits/Door to door – How often ● Radio talk/TV shows etc. – How often 7. Please comment on the effectiveness of each of the various measures put in place to enable young people in this community to access and utilize the needed SRH services

SRH service provision at the health facility during the lockdown 8. What different SHR services were available to young people at the/this health facility during the lockdown? Probe about ● Family planning services (ask about specific products/methods provided) ● SRH information and education ● HIV/AIDS Counselling and Testing ● Screening for other STIs ● SGBV information and counseling ● Menstrual health and sexuality education ● Cervical cancer screening 9. In the case of SRH information and education, please ask about ● The different SRH issues discussed with young people ● Relevance of topics discussed/presented to needs of young people ● The different methods/approaches used e.g group discussion, Q&A sessions, drama, videos/television Page 90 of 118

● Relevance of the methods/approaches used to educate young people 10. How frequently available were these services e.g hours a day, days a week? 11. Please comment on the adequacy and quality of SRH service provision to young people at the health facility during the lockdown. Probe about: ● Adequacy of facilities e.g space ● Adequacy of equipment and tools ● Friendliness of staff/providers ● Level of privacy in service provision ● Affordability/costs of services 12. Please comment on the level of young people’s uptake and utilization of these services during the lockdown (Probe about uptake for males and females, People with Disabilities, People Living with HIV/AIDS, those from remote areas, teenage mothers, out of school youths and other key populations) 13. What were the major challenges/barriers to young people’s access and utilization of SRH services and information during the lockdown? Probe about: Transport, curfews, restrictions to gatherings, product stockouts, lack of staff etc. 14. What more could have been done to improve young people’s access to and utilization of SRH services during the lockdown? 15. What measures were put in place to prevent the spread of COVID-19 among young people accessing SHR services and information at the health facility? Probe: How satisfied are you with these measures?

Role in the provision of SRH Services and Information during the lockdown 16. What was your specific role in the provision of SRH services and information to young people during the lockdown? Probe: How often/frequently e.g hours a day, days a week, were you available/engaged to support SRH service provision to young people during the lockdown? 17. How were you supported to execute this role? Probe about training, transport, other allowances, tools, and equipment etc. 18. What challenges did you and others like you encounter in providing SRH services and information to young people during the lockdown? 19. What key/important lessons have you learnt as a result of your involvement int his project (Focus on lessons that can improve/enhance the delivery, access to and utilization of SRH services and information) by young people especially during crisis 20. What more could have been done to better facilitate you and others like you to provide SRH services to young people during the lockdown?

ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

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Annex 7: Interview Guide for Health Workers / In charges of Health Facilities (Record Position, Age, Sex, and telephone contact of Respondent)

1. What were the major SRH issues/concerns of young people in this community during the lockdown? Probe about teenage/unplanned pregnancies, abortions, HIV/AIDS, STIs, Defilements and other SGBV issues 2. What various interventions did you implement to respond to the SRH needs of young people during the lockdown ● Health facility/youth centre/corner talks – How often ● Community outreaches/discussions – How often ● Community drives / megaphones – How often ● Radio talk/TV shows etc. – How often 3. Please comment on the effectiveness of each of the various measures put in place to enable young people in this community to access and utilize the needed SRH services 4. Please comment on the level of young people’s uptake and utilization of these services during the lockdown 5. What were the major challenges/barriers to young people’s access and utilization of SRH services and information during the lockdown? Probe about: Cost/charges of services, Transport, curfews, restrictions to gatherings, product stockouts, lack of staff etc. 6. What support did you receive to enable you better provide SRH services to young people during the lockdown? Probe about ● Support from the district ● Support from Reach A Hand Uganda ● Support from the Central Government / MOH ● Support from other NGOs/CSOs 7. What challenges did you experience in providing SRH services to young people during the lockdown? Probe about Transport, curfews, product stockouts, lack of staff, lack of facilities/equipment etc. 8. What more could have been done to facilitate you to better provide SRH services to young people during the lockdown? 9. What other recommendations/suggestions do you offer for improving provision of SRH services and information to young people?

ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

While conducting household interviews, KIIs or FGDs, interviewers should look out for unique cases/stories for follow up with a more in-depth investigation and documentation using this case documentation guide. Such might be cases evidencing success for example where an innovative method was used to provide Page 92 of 118

SRHR services to young people in hard-to-reach areas or where young people or peer leaders mobilized to take action to tackle pressing challenges in their community such as early/premarital sex and the associated problems including teenage pregnancies, early marriage, unsafe abortions etc. Cases could also be about an unfortunate/nasty/undesirable incident e.g the impact of covid-19 and the lockdown on jobs/employment, livelihoods, family harmony/solidarity, access to health etc.

Annex 8: Case Study Documentation Guide 1. What is the case about (child marriage, teenage pregnancy, defilement (Please describe in detail the nature of the issue/problem/case)? 2. Where did this happen (village, parish, sub-county, within the family, in the community, at the health facility etc.) 3. When did this happen (month, day, time, during the lockdown)? 4. Who was affected by this issue (child, parents, health workers etc.)? 5. How did this situation affect those involved? 6. What was done to address this issue/case/problem and by who? 7. What was the outcome of this intervention i.e., how helpful was this support/intervention? 8. What do those involved/affected learnt from this case/event?

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ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

Annex 9: Service Point Records Review Form NAME OF HEALTH FACILITY 1. Youth Corner 2. Youth Centre 3. Undesignated

TYPE OF OUTLET

CONTACT PERSON AT OUTLET AND TEL. CONTACT

NAME: TEL CONTACT:

DISTRICT SUB-COUNTY (IF APPLICABLE) DATE OF VISIT NAME OF PERSON COMPLETING THIS FORM

Please record the number of Service Users aged 10-24 who have used the following services before, during and after the lockdown Before the lockdown (Jan, Feb, and Feb 2020)

Total Jan

Number received FP/SRH education & counseling Number tested for HIV Number tested for other STIs Number receiving male condoms Number receiving other modern FP method Number referred for other services

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Feb

March Male

Female

Total

Before the lockdown (April, May, and June 2020)

April

May

June Male

Female

Total After lockdown (July, Aug, and Sep 2020)

July

Aug

Sep Male

Female

Prior to the study (Jan, Feb, and March 2021)

Total Jan

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Feb

Mar Male

Female

ASSESSMENT OF THE IMPACT OF THE COVID 19 RESPONSE ON YOUNG PEOPLE’S ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) IN MAYUGE DISTRICT

Annex 10: Facility Assessment Questionnaire (To be administered to In-Charges of Youth Centres/Corners) SECTION 1A: IDENTIFICATION NO 101

QUESTION District

RESPONSE 1. Mayuge

102

Sub-county

1. Mpongwe 2. Baitambogwe

103

Name of Health Facility

104

Level of Health Facility

105

Ownership of Health Facility

106

Date

107

Name of Interviewer

1. Hospital 2. HCIV 3. HCIII 4. HCII 1. Public Health Facility-PHF 2. Private not for profit (Mission/NGO) 3. Other private facility DD MM YY __ __ /__ __/ __ __

SECTION 1B: PROVIDER CHARACTERISTICS- RESPONDENTS PROFILE No Question

Response

Q10 8

Gender of respondent: (Observer, don’t ask)

1. Male 2. Female

Q10 9

Position of the respondent

1. In charge 2. Other

Q11 0

How long have you been working at this health facility? [Enter number]

|__|__| years (if less than 1 year, write 00)

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Cod e

Ski p

SECTION II: PROVISION AND ACCESSIBILITY OF SRHR SERVICES FOR YOUNG PEOPLE Instruction: Young people refer to males and females 10-24 years. Responses and No Question Codes Does this facility have a designated place e.g 1. Yes Q20 standalone centre or corner for providing SRHR 1 2. No services and information to young people? Is there a signage at the gate of the Facility 1. Yes Q20 welcoming young people or talking about youth 2 friendly SRHR services and information? (Please 2. No observe) Is there a signage on the front of the Facility 1. Yes Q20 welcoming young people or talking about youth 3 friendly SRHR services and information? (Please 2. No observe) In total, how many staff (excluding volunteers and Q20 peer workers) at this facility/youth centre/corner ……………………. 4 are involved in the provision of SRHR services and information to young people? 1. Yes Q20 Have some of these staff received training on how to 5 provide youth friendly SRHR services? 2. No How many staff (excluding volunteers and peer Q20 workers) have been trained to provide youth …………………… 6 friendly SRHR services and information? Among the staff engaged in the provision of SRHR 1. Yes Q20 services and information to young people at this 7 2. No facility, do you have any below 30 years? Q20 How many staff providing SRHR services to young …………………… 8 people at this facility, are below 30 years? 1. Yes Q20 Does the facility work with peer leaders/volunteers 9 to provide SRHR services to young people? 2. No Ho many peer leaders/workers/volunteers does this Q21 …………………… facility work with to provide SRHR services and 0 information to young people? 1. Yes, Always Is this facility open after-school hours (Beyond 5:00 Q21 2. Yes, Sometimes Pm) to provide SRHR services and information to 1 young people? 3. No/Never 1. Yes, always Q21 Is your facility open on weekends to provide SRHR 2. Yes, sometimes 2 services and information to young people? 3. No/Never Does this facility organize community outreaches to 1. Yes Q21 provide SRHR services and information to young 3 2. No people? 1. At least once a week 2. At least once a month How often does this facility organize community Q21 3. At least once every 3 outreaches to provide SRHR services and 4 information to young people? months 4. Other specify Does this facility organize school outreaches to 1. Yes Q21 provide SRHR services and information to young 5 2. No people? 1. Yes, Always Does your Facility provide subsidized and/or free Q21 2. Yes, Sometimes services for young people? (e.g., subsidized by 5 organization, projects, government, insurance, etc.) 3. No/Never Q21 Can young people access SRHR services regardless of 1. Yes 6 their ability to pay? 2. No

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Skip

2, skip to 207

2, skip to 209

2, skip to 211

2, skip to 215

PROVISION OF SRHR SERVICES DURING THE LOCKDOWN PERIOD (April to June 2020_ Which of the following SRHR services do you Q20 usually provide at this facility? (read out the 1 options to the respondent) a. Contraceptive counselling 1. Yes 2. No b. Oral contraception (Pills) 1. Yes 2. No c. Condoms 1. Yes 2. No d. injectable 1. Yes 2. No e. IUD 1. Yes 2. No f. Implant 1. Yes 2. No g. Emergency contraception 1. Yes 2. No h. Post Exposure prophylaxis (PEP) 1. Yes 2. No i. Child Delivery 1. Yes 2. No j. Treatment for incomplete abortion 1. Yes 2. No k. Post-abortion counselling 1. Yes 2. No L. Pre-/post HIV test counselling 1. Yes 2. No m. At least one RTI/STI treatment method 1. Yes 2. No n. At least one RTI/STI laboratory test 1. Yes 2. No o. Screening for sexual and gender-based 1. Yes 2. No violence 1. Yes 2. No p. Pregnancy testing 1. Yes 2. No q. Essential pre-natal care 1. Yes 2. No r. Essential post-natal care 1. Yes 2. No s. Sex and sexuality counselling 1. Yes 2. No t. Relationship counselling 1. Yes 2. No u. SGBV counselling 1. Yes 2. No v. Life skills counselling (Problem solving, 1. Yes 2. No creative and positive thinking, handling stress among others) Q20 For each of the SRHR services usually provided at this facility, please mention if it was 2 always available or not available during the lockdown (April to June 2020) 1. Always available a Contraceptive counselling 2. Available sometimes 3. Not available 1. Always available b Oral contraception (Pills) 2. Available sometimes 3. Not available 1. Always available c Condoms 2. Available sometimes 3. Not available 1. Always available d injectable 2. Available sometimes 3. Not available 1. Always available e IUD 2. Available sometimes 3. Not available 1. Always available f Implant 2. Available sometimes 3. Not available 1. Always available g Emergency contraception 2. Available sometimes 3. Not available 1. Always available h Post Exposure prophylaxis (PEP) 2. Available sometimes 3. Not available 1. Always available i Child Delivery 2. Available sometimes

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Treatment for incomplete abortion

Post-abortion counselling

Pre-/post HIV test counselling

At least one RTI/STI treatment method

At least one RTI/STI laboratory test

Screening for sexual and gender-based violence

Pregnancy testing

Essential pre-natal care

Essential post-natal care

Sex and sexuality counselling

Relationship counselling

SGBV counselling

v Q20 3

Life skills counselling (Problem solving, creative and positive thinking, handling stress among others) For services which were not always available during the lockdown period, please state the reasons

Contraceptive counselling

Oral contraception (Pills)

Condoms

injectable

3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available 1. Always available 2. Available sometimes 3. Not available

1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed

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IUD

Implant

Emergency contraception

Post Exposure prophylaxis (PEP)

Child Delivery

Treatment for incomplete abortion

Post-abortion counselling

Pre-/post HIV test counselling

At least one RTI/STI treatment method

At least one RTI/STI laboratory test

Screening for sexual and gender-based violence

Pregnancy testing

Essential pre-natal care

Essential post-natal care

Sex and sexuality counselling

4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock

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Relationship counselling

SGBV counselling

Life skills counselling (Problem solving, creative and positive thinking, handling stress among others)

Q20 4

During the lockdown period, was this facility/youth centre/corner supported by any organization to provide SRHR services to young people?

Q20 5

Which organization supported this facility/youth centre/corner to provide SRHR services?

Q20 6

What kind/form of support did this facility/youth centre/corner receive to provide SRHR services to young people during the lockdown?

Q20 7 Q20 8

Please comment on the adequacy of the support received by this facility/youth centre/corner to provide SRHR services during the lockdown? Please comment on the usefulness of the support received by this facility/youth centre/corner to provide SRHR services during the lockdown?

Q20 9

Overall, what factors constrained this facility/youth centre/corner’s ability/capacity to provide SRHR services to young people during the lockdown period?

Q21 0

What could have been done to enable this facility/youth centre/corner to better provide SRHR services to young people during the lockdown

2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Out of stock 2. No staff to provide 3. Facility closed 4. Others 1. Yes 2. No 1. Reach a Hand Uganda 2. Other NGO 3. Local Government 4. Central Gov’t/Ministry 5. Other (specify) 1. Product stocks 2. Provision of housing at the facility 3. Support with transport 4. Supported to make outreaches 5. Supported to make radio/TV talk shows 6. Other (specify) 1. Very Adequate 2. Fairly adequate 3. Inadequate 1. Very useful 2. Somewhat useful 3. Not useful 1. Product stockouts 2. No staff to provide 3. Lack of reliable transport 4. Restriction on movement/Curfews 5. Restrictions on assembly 6. Others (specify) 1. Adequate stock 2. Provision of housing at the facility 3. Support with transport 4. Allowed to make outreaches 5. Supported to make radio/TV talk shows 6. Other (specify)

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Annex 11:

List of Key Informants Interviewed

1. District Health Officer (ADHO) 2. District Health Educator (DHE) 3. District Secretary for Health and Social Services 4. Community Development Officer - Mpungwe Subcounty 5. Secretary for Health and Social Services - Mpungwe Subcounty 6. Community Development Officer - Baitambogwe Sub-county. 7. Health Assistant - Mpungwe Sub-county 8. Registered Nurse (For In charge Mpungwe Health Centre II) 9. In charge Baitambogwe Health Centre III 10. Health Assistant- Baitambogwe Sub-county 11. In charge Mayuge H Health Centre III 12. Health Information Assistant- Mayuge Health Centre III 13. Officer In Charge of Children and Family Protection Unit - Mayuge Central Police Station 14. Crime Intelligence Officer - Mpungwe Police Post 15. Officer In Charge - Baitambogwe Police Station 16. Office Supervisor for Bache - CBO in Mpungwe Sub-county 17. Officer Supervisor at BRAC 18. Project Manager at Rights East Central

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Annex 11:

Letter of introduction endorsed by the District Authorities.

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References Asingwire, N., Muhangi, D., Kyomuhendo, S., & Leight, J. (2019). Impact Evaluation of YouthFriendly Family Planning Services In Uganda. Retrieved from https://developmentevidence.3ieimpact.org/search-result-details/impactevaluation-repository/impact-evaluation-of-youth-friendly-family-planning-servicesin-uganda/7181 Aventin, A., Gough, A., McShane, T., Gillespie, K., O'Hare, L., Young, H., . . . Lohan, M. (2020). Engaging parents in digital sexual and reproductive health education: evidence from the JACK trial. Reprod Health, 17(1), 132. doi:10.1186/s12978-020-00975-y Bakeera, S. K., Wamala, S. P., Galea, S., State, A., Peterson, S., & Pariyo, G. W. (2009). Community perceptions and factors influencing utilization of health services in Uganda. Int J Equity Health, 8, 25. doi:10.1186/1475-9276-8-25 Bulthuis, S. E., Kok, M. C., Amon, S., Agyemang, S. A., Nsabagasani, X., Sanudi, L., . . . Dieleman, M. A. (2021). How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana. Glob Public Health, 16(1), 120-135. doi:10.1080/17441692.2020.1791213 Buor, D. (2004). Determinants of utilisation of health services by women in rural and urban areas in Ghana. GeoJournal, 61(1), 89-102. Retrieved from http://www.jstor.org/stable/41147917 Dessie, Y., Berhane, Y., & Worku, A. (2015). Parent-Adolescent Sexual and Reproductive Health Communication Is Very Limited and Associated with Adolescent Poor Behavioral Beliefs and Subjective Norms: Evidence from a Community Based CrossSectional Study in Eastern Ethiopia. PLoS One, 10(7), e0129941. doi:10.1371/journal.pone.0129941 Gabrani, J., Schindler, C., & Wyss, K. (2020). Factors associated with the utilisation of primary care services: a cross-sectional study in public and private facilities in Albania. BMJ open, 10(12), e040398. doi:10.1136/bmjopen-2020-040398 Maina, B. W., Ushie, B. A., & Kabiru, C. W. (2020). Parent-child sexual and reproductive health communication among very young adolescents in Korogocho informal settlement in Nairobi, Kenya. Reprod Health, 17(1), 79. doi:10.1186/s12978-020-00938-3 Mambo, S. B., Sikakulya, F. K., Ssebuufu, R., Mulumba, Y., Wasswa, H., Thompson, K., . . . Kyamanywa, P. (2020). Factors that influenced access and utilisation of sexual and reproductive health services among Ugandan youths during the COVID-19 pandemic lockdown: An online cross-sectional survey. doi:10.21203/rs.3.rs-48529/v4 Mojumdar, S. K. (2018). Determinants of Health Service Utilization by Urban Households in India:A Multivariate Analysis of NSS Case-level Data. Journal of Health Management, 20(2), 105-121. doi:10.1177/0972063418763642 Othman, A., Shaheen, A., Otoum, M., Aldiqs, M., Hamad, I., Dabobe, M., . . . Gausman, J. (2020). Parent-child communication about sexual and reproductive health: perspectives of Jordanian and Syrian parents. Sex Reprod Health Matters, 28(1), 1758444. doi:10.1080/26410397.2020.1758444 Wandera, S. O., Kwagala, B., & Ntozi, J. (2015). Determinants of access to healthcare by older persons in Uganda: a cross-sectional study. Int J Equity Health, 14, 26. doi:10.1186/s12939-015-0157-z

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World Vision (2020). COVID-19 Aftershocks: Teenage pregnancy on the rise in refugee settlements. Retrieved from https://www.wvi.org/stories/uganda/covid-19-aftershocks-teenage-pregnancy-rise-refugee-settlements ii

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Madinah Nabukeera (2021) Prevention & response to gender-based violence (GBV) during novel COVID-19 lockdown in Uganda

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Impact of COVID-19 on household incomes and access to SRHR services by young people

Articles inside

Annex 8: Case Study Documentation Guide

Annex 11: Letter of introduction endorsed by the District Authorities

Annex 7: Interview Guide for Health Workers / In charges of Health Facilities

Annex 6: Interview Guide for Peer Educators

Figure 46: Overall coping strategies adopted by households

Annex 4: FGD Guide for Caregivers of Young People (Male and Female Annex 5: Interview Guide for District/Sub-county Health Officials and Political Leaders89

Figure 42: Young people’s satisfaction with SRH services received

Annex 3: FGD Guide for Young People (Male and Female) Aged 10-24 years

Figure 21: Community leaders’ support towards SRH of young people

Figure 41: Who paid for SRH services accessed by young people

3.4.6 Impact on health spending and utilization of SRH services

Table 12: Young people’s source of information of SRH during the lockdown

Figure 8: Reasons for not seeking SRH services

Figure 11: Contraceptive method used during last 12 months

Figure 7: SRH services sought and obtained during the lockdown

Table 4: Demographic characteristics of caregivers

Figure 6: Young people who sought and obtained SRH services

1.4.1 Objectives and research questions

Figure 9: Reasons for not obtaining the services sought

Figure 2: Forms of paid work engaged in by young people