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Background: The rate at which informal urban settlements (slums) are developing in Low and Middle Income. Countries (LMICs) like Uganda is high. With this, comes the growing intersection between urbanization and the reproductive health of key populations. Currently, a number of interventions are being implemented to improve the Reproductive Health (RH) of adolescents in Kisenyi, the largest informal urban settlement in Kampala, the capital of Uganda. Despite these efforts, adolescent RH indicators have persistently remained poor in Kisenyi. This could be indicative of a gap between the provided and needed adolescent RH interventions. We assessed the fit between the available interventions and the RH needs of adolescents living in Kisenyi. Methods: We conducted a qualitative study in July 2019–February 2020 in Kisenyi. The methodology was guided by the Word Health Organization global standards for quality-health care services for adolescents, the “For whom? Where? By whom? and What?” Framework of sexual RH service delivery and the realist evaluation approach. Eight focus group discussions were conducted with adolescents 15–19 years to explore their RH needs. The design and implementation of the available adolescent RH interventions were assessed by conducting Key Informant interviews with 10 RH service providers in Kisenyi. Validation meetings were held with adolescents and they scored the extent to which the various design features of the existing interventions fit the adolescents’ RH needs. Results: The available RH interventions focused on meeting the sexual RH needs like providing family planning services but less on social needs like livelihood and sanitation which the adolescents identified as equally important. While the providers designed intervention to target 10-24 year olds, the adolescents preferred to have interventions that specifically targeted the study population 15-19 years. Most interventions were facility-based while, the adolescents desired community based outreaches. Conclusion: The packaging and mode of delivery of interventions were perceived less holistic to meet the adolescents’ needs. Most interventions were designed to address the sexual and family planning needs while ignoring the wider social and livelihood needs. More holistic and outreach-based programming that addresses RH within the broader context of livelihood and sanitation requirements are more likely to be effective.
This study was conducted in Kisenyi Slum located in Kampala city, Uganda. Kampala city has the highest urban population growth rate in Uganda [26] and Kisenyi slum is the largest slum/ informal settlement located in the south-western part of Kampala Central Division [27]. Kisenyi has typical urban poor characteristics of; 1) informal settlements, 2) clusters of dilapidated housing, 3) large population size and 4) a rapidly expanding population [28]. Kisenyi is also categorized as a slum according to the urban planning documentation from Kampala Capital City Authority. Kisenyi is comprised of 3 parishes: Kisenyi I, Kisenyi II and Kisenyi III. Kisenyi II Parish is residential with a more stable population [29] and was purposively selected as the study area to give a representation of a typical adolescent that resides in this slum. Among the government aided adolescent RH investments in Kisenyi is a youth friendly corner at Kisenyi HCIV which has community outreaches through community health workers, also avails free condom dispensers in the community and radio sexual and RH programs for the youth [30]. Kisenyi HCIV also has affiliations with some institutions that majorly provide HIV/AIDS services. Other NGO led investments include youth health and sports centers and a few youth vocational training centers. Kisenyi has a public primary school under universal primary education and other social services like churches, sports play grounds, faith based home shelters and some privately owned group homes. This was a case study of a slum setting that employed mainly qualitative methods and was conducted between July 2019 and February 2020. The primary study population were adolescents aged 15–19 years living in Kisenyi slum. The study also included implementers of adolescent RH interventions as key informants. To explore the Reproductive Health needs of the adolescents, eight focus group discussions (FGDs) were conducted involving 85 participants. The FGDs were held with the adolescents aged 15–19 years and had lived in Kisenyi for the last 1 year. The eligible adolescents were purposively identified by village health team (VHT) members-a cadre of community health workers. Once identified, the VHTs mobilized them to a central community venue decided upon by VHTs and the adolescents. At the venue, the researchers privately screened each adolescent by asking each one of them secretly (self-report) in order to stratify them by sex, schooling status, being sexually active, marital status and ever having a child i.e. criterion sampling [31]. Five FGDs were for males and three for females with details per sampling criteria in Table 1. Written informed consent was sought from the study participants aged 18–19 years, emancipated minors aged 15–17 years and from parents/guardian of adolescents below 18 years (for adolescents still under parental custody at the time the VHTs invited them to the venue). Written assent was sought from non-emancipated minors/adolescents aged 15-17 years. Characteristics of the FGD participants During the FGDs the adolescents described their RH needs, listed key providers of RH and related interventions in their community based on the FGD guide developed by the authors for the purpose of this study. When describing the RH needs, the adolescents were probed to enlist their comprehensive needs in the medical, social and developmental domains according to standard 3 of the WHO global standards framework [24]. According to the standard, examples of medical needs are: information, counselling, diagnostic, vaccination, treatment and care services that fulfils the SRH needs of all adolescents. Social needs may include parental support, housing and education while, developmental needs may include substance abuse control and prevention of violence and unintentional injuries. The FGDs were conducted in the local language known to all participants that is Luganda. Transcripts from the FGD were analyzed to summarize the list of medical, social and development needs mentioned by the Adolescents. To describe scope and the design of available RH interventions, we conducted key informant interviews (KIIs) with service providers (urban authorities and implementing partners). We identified the first five KIs based on the discussion held with the adolescents when they listed key providers in Kisenyi. We identified the rest of the service providers using the snow balling technique by asking the key informants initially interviewed to name the other service providers that they know of who provide youth reproductive health interventions in Kisenyi. A total of 10 KIIs were conducted and their characteristics are shown in Table 3. The interviews were conducted using the KII guide developed by the authors for the purpose of this study. During the interviews, we first asked the service providers to describe the reproductive health interventions that they provide to the adolescents in Kisenyi. The “For whom? Where? By whom? and What?” Framework of SRHS delivery by Denno and colleagues [6] was adapted and used to interview service providers and urban authorities when asked to describe the scope of their interventions. For example, whether the intervention is school or community based or whether the intervention targets one or both males and females. We also probed the KIIs on whether they offered any services aligned with the medical, social and development needs that had been earlier mentioned by the Adolescents. In addition, we applied the principals of the realist evaluation [32] to probe the design and implementation features of the interventions that each provider was implementing in Kisenyi slum in order to assess whether they align with target population (adolescents’) context. The design features probed are summarized in Table 2. Intervention design features probed during Key informant interviews Probed the list of intervention that each provider is implementing according to the following categories: 1) health awareness (any intervention targeting to provide preventive and promotive health information); 2) violence prevention (any intervention to control violence, treat and rehabilitate victims); 3) mental health (any intervention for rehabilitation of psychosocial morbidities); 4) substance abuse (any intervention for drug use and tobacco use control); 5) sexual health (any intervention on safe sex counseling, family planning services access, HIV/AIDS testing and treatment and 6) maternal child health services (any intervention on safe motherhood and newborn care) List of de-identified key informants and the nature of services that they mainly provide Using content analysis, we summarized the number of providers implementing at least one intervention with the respective design features. Depending on the number of interventions provided within a respective design feature across the 10 service providers, each design feature was allocated counts to determine the most prevalent design characteristics. This information was visually presented using graphs and the qualitative quotes from the KIs provided the descriptions and explanations. Because of the broad definition of the design feature on “scope of interventions”, we presented the scope of this feature in a figure for better interpretation. To determine the extent to which the available RH intervention designs fit the RH needs of the adolescents, we used deliberative multi-voting approach [33]. We held two community consultative validation meetings with 26 representatives of the adolescents engaged in the initial FGDs. This included 11 males in one validation meeting and 15 females in the other. During the meetings, 1) we presented to the adolescents the summary of their RH needs from the FGD analysis on a flip chart pasted on a wall and asked them to validate and prioritize the needs. The RH needs were categorized into sexual health and social needs as the main themes from the FGD analysis. Under each theme the adolescents were asked to individually choose their top 3 priority needs in sexual health category and top 2 priority needs in the social needs category. The adolescents used stickers to indicate their choice and each adolescent had a maximum of five stickers (three for sexual health and two for social needs). 2) The adolescents were also presented with the list of 10 service providers of RH interventions (named as provider 1, provider 2 and so on) with whom we held KIIs with. On the flip chart with the list of providers, we included a description of the nature of services per provider and the design features of each of the interventions provided. We asked the adolescents to score the extent to which the design of the interventions met their (adolescent) prioritized RH needs elicited in the sticker exercise described above. They scored the following design features that are adopted from the “For whom? Where? By whom? and What?” Framework of SRHS delivery, also described in Table 2 of the methods section: The key areas of inquiry were: 1) whether the intervention scope covered their priority RH needs; 2) whether the interventions targeted their age group; 3) whether the delivery model used for the interventions was adequate; 4) whether the interventions fit the urban poor context in terms of the beneficiary category and 5) whether the intended outcomes of the interventions aligned with their needs as articulated by them in the sticker exercise. The scores were based on the scale of 0–5: 0 = not aware of the intervention or design used; 1 = Poor fit of the design; 2 = Moderate fit of the design; 3 = Good fit of the design; 4 = Excellent fit of the design and 5 = Exceptional fit of the design. A single score per design feature was collectively agreed by consensus in the respective male and female validation meetings and allocated for each provider (in the respective design feature of inquiry). After the meeting, the “male meeting” and “female meeting” scores were entered in excel and mean scores were derived for each design feature for all providers as a whole (aggregate score per design feature). During the meetings, the adolescents gave explanation for each score they agreed to allocate. After descriptive analysis, the aggregate mean scores were compared to the maximum possible mean score per design feature (which in this case was five) to determine the extent to which the design of the available RH interventions fit the RH needs of the adolescents. A radar chart was used to demonstrate the comparison. The radar chart plots the aggregate scores per design feature against the maximum possible mean score per design feature. The equi-angular spokes or radii show which of the design features is perceived to meet the adolescent RH needs the most and which one meets the adolescent needs the least across the interventions scored. The descriptive analysis was supplemented with the explanations provided by the adolescents during the validation meetings. The FGDs, KIIs and validation meeting were facilitated by the Principal Investigators who have a good working knowledge of English and Luganda. During the interviews, open ended questions were asked followed by targeted questions (probes) on predetermined themes. Throughout the study, the team adhered to the RATS guidelines on qualitative research [34] in terms of 1) the Relevance of study design in answering the research question; 2) Appropriateness of qualitative method such as use of FGDs and KIIs; 3) Transparency of procedures in sampling respondents and 4) Soundness of interpretive approach as applied to the data analysis. During each interview, a Note taker was available to take notes. All the qualitative interviews were audio recorded with consent of the participants and then transcribed verbatim. The transcripts were analyzed using Atlas Ti vesion 8. A conventional content analysis approach was used for the qualitative data as described by [35]. The qualitative analysis was done in two stages; first, the manifest content analysis and then the latent content analysis. The transcripts were read and codes were derived by highlighting emerging issues based on our understanding of the data. Codes were then sorted into categories based on their linkages. The categories were grouped together into meaningful overarching themes i.e. RH needs of adolescents for objective one, design features of interventions for objective two and reasons for the assigned score on extent of fit of intervention design and RH needs for objective three. Key quotations that epitomized central themes related to the main findings are presented in the results. The Lead Researchers TD, BS and SS conducted the data analysis and synthesis. The information on the flip charts from the validation meeting scores was immediately entered into Microsoft excel to avoid loss of the hard copy data. Descriptive analysis was conducted and results presented in figures. Where appropriate, quantitative and qualitative results were presented together in order to enhance contextualization of the results. This study was approved by the Makerere University School of Public Health Higher Degrees Research and Ethics Committee (HDREC protocol number 669) and registered by the Uganda National Council of Science and Technology (Ref SS 5093). Permission was also sought from Kampala Capital City Authority and local leaders in Kisenyi Slum. The following ethical principles were upheld in the study; 1) anonymous data collection strategies to maintain a high level of confidentiality; 2) informants were asked to participate voluntarily; 3) written informed consent or assent; and 4) no study materials contained names or other explicit identifiers of participants. For confidentiality purposes, information on sexual undertakings of the adolescents discussed in the FGD were not attributed to any group member but was treated as generic needs for people in the age category. After each FGD, the study team demystified any misinformation, myths and misconceptions that were identified during the FGDs. All participants mobilized were given a modest fee of Uganda shillings five thousand (equivalent to USD 1.5) as refund for their transport to the venue. Permissions from participating organizations (service providers) was sought. Names of the participating organizations were obtained for use if corrective actions were to be undertaken and the organizations consented to have their names used in publication with the overriding principle of do no harm.
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