Mitigating Adverse Sexual and Reproductive Health Outcomes Through a Comprehensive Primary School Sexuality Education Program in South-Western Uganda
Phase: NA
Conditions: Relationship Problems Specific to Childhood and Adolescence
Sponsor: Mbarara University of Science and Technology

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Mitigating adverse sexual and reproductive health outcomes through a 
comprehensive primary school sexuality education program in South-
Western Uganda’. 
 
Principle Investigators 
Dr. Viola Nyakato, Mbarara University of Science and Technology (MUST), Uganda  
Dr. Kristien Michielsen, International Centre for Reproductive Health (ICRH), Ghent 
University, Belgium 
 
 
Co- Investigators  
Dr. Elizabeth Kemigisha Mbarara University of Science and Technology (MUST), Uganda  and  
International Centre for Reproductive Health (ICRH), Ghent University, Belgium 
Prof Dr. Gily Coene, RHEA Centre of Expertise in Gender, Diversity and Intersectionality Free 
University of Brussels, Belgium  
Dr. Els Leye, RHEA Centre of Expertise in Gender, Diversity and Intersectionality Free 
University of Brussels, Belgium  
Dr. Solome Najjuka, Uganda Martyrs University, Uganda   
Ms. Mlahagwa Wendo, Department of Gender and Women Studies, Mbarara University of 
Science and Technology, Uganda 
Mr. Gad Ruzaaza, Community Based Education Programme, Faculty of Medicine, Mbarara 
University of Science and Technology, Uganda 
 
 
Time period: April 2015 to December 2018   
 
Funding channel: Flemish University Development Cooperation (VLIR-OUS) 
 
Total Budget: Euros 299,924 
 
Version 3 November 2016 
 
 
I. 
Project Description  
Adolescent sexual and reproductive health is a major public health concern in Uganda and many 
countries around the globe. This project seeks to contribute to this developmental problem by 
tackling it at the roots: while most ASRH interventions focus on older adolescents that are 
already sexually active, our project takes a step back and addresses young adolescents before 
they become sexually active. 
 
The overall project objective is to improve adolescent sexual and reproductive health (ASRH) 
through comprehensive sexuality education for young adolescents in South Western Uganda 
using a university student outreach programme. Firstly (IR1), we assess the gaps in SRH 

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education using mixed methods. Second (IR2), we will develop an interdisciplinary ASRH 
school model with integrated gender-perspective for young adolescents in primary schools. 
This model builds on existing initiatives (UNESCO, IPPF, Rutgers WPF) and will be 
implementing by interdisciplinary teams (biomedical and gender studies students) within the 
framework of the existing university students outreach programme of Mbarara University. 
Thirdly (IR3), the development and implementation will be closely monitored to identify 
enabling and hindering factors, and the effectiveness of the ASRH school model will be studied. 
Finally (IR4), the findings will be disseminated. The project is innovative for two main reasons. 
1) It focuses on young adolescents: even though the stage of early adolescence is one of the 
most crucial phases of human development, it is often overlooked in SRH research. 2) The 
project pays specific attention to the process of development and implementation of a 
comprehensive SRH program. While effectiveness studies have been done on this topic, good 
process and implementation research is very rare. Nevertheless, it is crucial for the advancement 
of the study field. 
 
This project also provides a collaborative platform between stakeholders in the Gender and 
Women Studies Department at MUST and the International Centre for Reproductive Health 
(ICRH) at the University of Ghent and the Center of Expertise on Gender, Diversity and 
Intersectionality (RHEA) at the Free University of Belgium as all parties benefit from the 
collaborative research which will lead to joint PhDs and publications in the field of adolescent 
health. 
II. 
Background and Relevance  
Currently, there is hardly any standardized sexuality education curriculum for primary school 
students in Uganda (Darabi, Leila, et al., 2008).The sexual education programs which are in 
place are often for secondary education and the out of school adolescents. In Uganda, only 
about half of sexually active 15-19 year olds have ever received any kind of sexual education 
in school (Darabi, et al., 2008). The education factor clearly impacts sexual behavior, with the 
average age of first sexual encounter rising to 18.1 for women and 18.3 for men for those who 
have attained secondary level education. The average age of first sexual encounter between men 
(18.2) and women (16.2) with no education, and men (18.0) and women (16.3) who have 
attained primary school is nearly the same, whereas the average age of first sexual encounter 
for those with secondary education increases dramatically only for girls (UDHS 2012).  

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A research project involving Uganda and other Sub-Sahara African countries identified three 
core positive outcomes for adolescents health interventions: delayed sexual initiation, risk 
reduction for sexually active youth and reduced incidence of pregnancy or STIs (Advocates for 
Youth 2005). However, among all researched countries there was no evidence of intention to 
continue intervention since most of the researched outcomes were not studied on a long-term 
in scope, and the study process did not offer a consistent approach to sexuality education 
Uganda implements a school health program under the ministry of Education providing 
comprehensive preventive and health promotion services to school going children (5-24years). 
The main purpose of the most research intervention is to improve sexual and reproductive health 
of school children. The efforts however have not been sufficient as AIDS and other sexual and 
reproductive health problems continue to pose a serious threat to young people.  
 
Uganda’s sexual and reproductive health trends undoubtedly indicate that primary school is a 
critical stage at which interventions would arguably have the most profound impact in the long-
term. With the advent of universal primary education, access to primary school for students is 
far more accessible than secondary school, which remains out of reach for many. On average, 
85% of urban children and 80% of rural children enroll in primary school, revealing the high 
level of access to primary education (Uganda Demographic and Health Survey (UDHS) 2011). 
However, 68% of children who enroll for primary education drop out of school before reaching 
the last grade. Uganda’s primary school dropout rate is the second highest in Sub-Saharan 
Africa, where more than 2 out of 3 children starting primary school are expected to drop out 
before reaching primary seven (UNESCO 2012).  The transition between primary and 
secondary school reveals a sharp drop off in attendance rates across the region with a particular 
discrepancy for rural areas. In urban areas, 34.7% of students continue with secondary school, 
whereas in rural areas only 14% of students continue on. Access to secondary school also 
suffers from a gendered divide. Only 12.6% of young men continue with secondary school, 
compared to the 15.5% of young women who continue in rural areas. In urban areas this gender 
divide is flipped, with 39.7% of young men continuing on to secondary school, compared to 
just 31% of young women (UDHS 2011). 
 
This research uses an intervention approach to address this gap through implementing a long-
term and consistent approach for a sexuality education program for young adolescents attending 

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primary school in South-Western Uganda. The program will be implemented as part of the 
Community Based Education program of Mbarara University of Science and Technology 
(MUST). After a baseline survey, a sexuality education curriculum will be designed by the 
study investigators in partnership with all relevant stakeholders. The sexuality education 
curriculum will be adapted to already tested SRH education models and sexuality education 
guidelines that have worked in Uganda. Through the Community Based Education program, 
university students will be grouped in interdisciplinary teams which will include biomedical 
and gender studies students of MUST. The implementation will be supervised by a team of 2 
to 3 jointly supervised PhD students conducting their academic research on the project.  
 
This is an initiative that is spearheaded by the Department of Gender and Women Studies and 
the Community Based Education (CBE) Program, Mbarara University of Science and 
Technology (MUST). University students of MUST will be teamed up in interdisciplinary 
teams comprising of gender and biomedical medical students to deliver comprehensive 
sexuality education programs to adolescents in selected primary schools in South-Western 
Uganda.    
III. 
Problem analysis  
Uganda’s adolescents experience unfavorable outcomes resulting from inadequate sexual and 
reproductive health information and risky sexual practices. Young people (10-24 years) 
constitute over 33.5% of Uganda’s population, with about 47% below the age of 15 (UBOS 
2012). Nevertheless, this age group carries the highest disease burden, particularly in the sexual 
and reproductive health area. Trends indicate that young people continue to account for half of 
HIV/AIDS new infections, with signs of increased risky sexual behaviours (Kibombo et al 
2008, UNAIDS 2013). In Uganda, young people suffer from negative sexual and reproductive 
health outcomes such as unintended pregnancies, unsafe abortion, maternal mortality, sexually 
transmitted infections (STIs), HIV/AIDS, exploitation, sexual violence against young women 
and girls,  increasing number of adolescents with prenatally acquired HIV, and poor nutrition 
(Baryamutuma and Baingana 2011). There are higher rates of STIs and HIV infection with 
adolescents than in the general population (MOH, 2009), and about 2.1 million adolescents are 
known to be living with HIV in Uganda today (UBOS 2012). According to the UNAIDS 
epidemiological report of 2013, 39% of the new infections in Uganda and other in other Sub-
Saharan countries were among young people between the age of 15 and 24 (UNAIDS 2013). 

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Furthermore, pregnant adolescent girls are more susceptible to pregnancy- and childbirth-
related complications because they have not yet developed the physical maturity required for a 
healthy pregnancy (Chen et. al., 2006). 
 
The Uganda government survey on demography and health indicates that there is a higher 
morbidity and mortality rate among pregnant teenagers and their babies than among older 
women (Republic of Uganda, 2006: 62). The issues are related to HIV/AIDS, STD’s, unplanned 
pregnancies, abortion, contraceptive use, gender-based violence, cross-generational sex, and 
female genital mutilation. For the youth of Uganda, particularly young women, there is a 
plethora of adverse health effects caused by under-informed sexual and reproductive health 
decisions, which has serious implications for the future health and safety of the Ugandan 
population.  The high prevalence of gender based sexualised violence among adolescents in 
Uganda associated with forced sex, unwanted sexual touches, forced marriage and abortion 
among young girls than boys. It is estimated that over 20 young girls are defiled every year in 
Uganda, the trend is on increase (UBOS 2012). 
IV. 
Research Objectives and Questions 
The aim of this research is to develop a comprehensive sexuality education (CSE) program 
targeting young adolescents in primary school in South-Western Uganda. This effort is aimed 
at improving adolescent sexual and reproductive health of young adolescents through CSE that 
is led by interdisciplinary university students’ team in an environment where no consistent or 
regulated sexual and reproductive health education program currently exists. 
In line with the above project aim, the following specific research objectives have been 
identified:  
1. To assess the current of SRH knowledge, attitudes towards SRH education and SRH 
behaviors among young adolescents in south western Uganda  
2. To examine and understand factors that increase young adolescents vulnerability to 
SRH risks such as unsafe sex, sexual  coercion and early pregnancy  
3. To assess (perceived) barriers to implement sexual and reproductive health education at 
the primary school level in Uganda  
4. To develop a gender sensitive comprehensive SRH education for primary school going 
young adolescents  

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5. To explore the effectiveness of university students’ led SRH education program for 
primary school going adolescents on young adolescents’ sexual health and wellbeing. 
The following list of research questions (none exhaustive) will be the focus of the research:  
1. What is the state of SRH knowledge, attitudes towards SRH education and SRH 
behaviors among upper primary school going adolescents in South Western Uganda?  
2. What is the linkage between gender attitudes and young adolescents’ SRH risks?  
3. What are the barriers that inhibit sexual and reproductive health education at the primary 
school level in Uganda?  
4. Who are the SRH stakeholders and what is their focus?  
5. How can a comprehensive sexuality education program be implemented in primary 
schools? What are hindering and enabling factors? 
6. How effective is a university led SRH education in mitigating SRH risks?  
 
V. 
Literature review as per the research objectives  
At the United Nations at the International Conference on Population and Development (ICPD) 
in 1999 governments realized that investing in the health of adolescents is important not only 
for the well-being of adolescents but also for the current and future well-being of communities 
and societies (Chandra-Mouli et al, 2015).  When young adolescents have access to school 
based comprehensive sexuality education, they are better able to protect themselves against 
sexually transmitted infections (STIs), avoid unwanted pregnancy, care for their reproductive 
health and take advantage of educational and other opportunities that will affect their lifelong 
well-being. It is thought that this initiative on comprehensive primary school sexuality 
education would lead to the production of an information (data) base on adolescent sexuality 
practices and behavioral changes. The outcomes of a gender sensitive and comprehensive SRH 
school health model will be evaluated and contribute to the body of knowledge since very few 
comprehensive sexuality education programmes have been evaluated especially in as far as 
their impacts are concerned. 
 
The current state of SRH knowledge, attitudes towards SRH and SRH 
behaviors:Assessing the gaps in SRH education 
Handling of sexuality education in Ugandan primary school science curriculum focuses mainly 
on anatomy, changes during adolescence and fertilization, leaving out important aspects such 

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as gender based violence, prevention of sexually transmitted infections other than HIV, 
abortions and teenage pregnancy, communication about sexuality, gender equitable 
relationships, condom negotiation - thus the need to bridge the existing gap. There are also non- 
curriculum based preventive and health promotion programs such as Straight Talk Foundation 
and PIASCY (Presidential Initiative on AIDS Strategy for Communication to Youth) have had 
some coverage in Uganda but there is a still challenges of sustainability and their impact in 
remote areas. PIASCY program focuses mainly on HIV/Aids and abstinence. Some schools 
offer no sex education, since it remains a controversial issue especially with regard to the age 
at which children should start receiving such education and the amount of detail to be revealed.  
 
It has further been noted that in Uganda sexuality education has partly been offered through 
youth centres, the meeting points that offer a youth friendly, safe non threatening environment 
for information and service delivery across various sectors such as health, education, job 
training and reaction. However, reviews that were carried out about Youth centres across the 
globe indicated that these centres were not likely to be a cost-effective way to increase the use 
of SRHS because of high operating costs associated with provision of multiple (including none 
health related) services (Denno et al, 2015). Globally, the number of adolescent sexual and 
reproductive health programmes documented in the literature is substantial, with varied designs, 
but there are comparatively few at national scale or with reliable periodic evaluation (Haberland 
et al , 2015) 
 
Following the 2007 global assessment of youth-friendly primary care services that examined 
the benefits and effectiveness of accessing youth-friendly health services and facilities on health 
outcomes, a number of conclusions were drawn about the need for stronger research and 
evaluation. The well-documented barriers faced by young people in accessing services had not 
been addressed in a comprehensive way, and the evidence for the effectiveness of youth-
friendly initiatives was inadequately measured against young peoples’ health outcomes. 
Although utilization had often increased, there was little clear evidence that making services 
youth-friendly, and securing the investments required to do so, improved health outcomes. The 
study called for systematic and well-designed interventions with regular assessments, and for 
interventions to incorporate targets and principles into their design and to assess their strategies 
against these targets (Report on Programme of Action of the International Conference on 
Population and Development, 2014).   

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Indeed in Uganda, whereas Youth Friendly Corners (YFCs) have been formed by Health centers 
to cater for the needs of adolescents and providing sexuality education, they have been faced 
with challenges calling for a change of approach in the delivery of sexuality education. And 
this probably calls for a school based sexuality education program as the best option basing on 
the teachers’ responses above. In the same vein, a study conducted elsewhere in Uganda showed 
that YFCs were not functioning properly. It was further noted that in the YFCs where equipment 
has been provided to watch educational films have only been provided on condoms, family 
planning, HIV/STIs and male circumcision. The young people are now bored with these films 
and in some instances they have started watching Nigerian films and in other districts they 
simply watch entertainment films. Indeed as the teachers in Mbarara pointed out, studies also 
revealed that youth friendly clinics located in HC IVs and district hospitals tend to focus on all 
health conditions, not only sexual and reproductive health (Homans et al, 2013). It is in the 
view of the above existing gaps in adolescent sexuality education that this project is being 
implemented.  
 
Integrating gender-perspective into ASRH in primary schools 
A number of funded programs and researchers across the globe have increasingly highlighted 
gender as a topic integral to comprehensive sexuality education. It should be noted that 
conventional sexuality education focuses on physiology and sexual and reproductive health, but 
does not address issues of gender and power. By contrast, comprehensive sexuality education 
(CSE) focuses on physical, emotional, social and cultural aspects in that, it is gender 
appropriate, based on human rights of the country, culturally responsive, basing on holistic 
concept of well being, it accommodates diversity and it is based on unbiased scientifically 
accurate information that empowers and equips young people with life skills to make 
autonomous and informed decisions. 
One recent review that considered only studies that utilized health outcomes as a measure of 
impact found that comprehensive sexuality education curricula that emphasized gender and 
power among other qualities  of holistic sexuality education were markedly more likely to 
reduce rates of sexually transmitted infections and/or unintended pregnancy than “gender-
blind” curricula (Haberland  & Rogow, 2015). In other words, the conventional programs 

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though they report a change in a behavioral outcome, they fail to demonstrate a remarkable 
impact on reducing pregnancies and STIs (Ibid).   
 
Indeed gender empowerment approach to comprehensive sexuality education; since it is 
directed to handling issues of gender, power and rights, it is likely to have positive outcomes 
on concerns about early marriage, sexual coercion, intimate-partner violence, homophobic 
bullying, girls’ agency, school safety, sex trafficking, among others.  
 
In underlying the importance of gender in sexuality education, Svanemyr et al ( 2015) have 
suggested creating safe spaces for adolescent girls in that social norms and taboos related to 
gender, sexuality, and SRH issues create a culture of silence, particularly for adolescent girls, 
in asking, obtaining information, discussing, and expressing their worries about SRH issues. 
This is particularly the case when it comes to communication with adults in the family or 
communities. Many girls have limited agency and mobility, few possibilities to express 
themselves without judgment, and know few persons and places to seek information and 
support. The lack of a confidential and judgment-free environment can be a barrier to girls 
obtaining SRH information, learn skills, and feel supported in expressing their concerns related 
to their lives and SRH issues. 
 
The above findings echo with other evidence on the value of addressing gender norms and 
relationship dynamics within comprehensive sexuality education. The approach has an explicit 
gender focus, and addresses gender norms and gender equality as stand-alone topics. For 
instance in some societies gender norms dictate that girls should marry and begin childbearing 
in their early or middle teenage years, well before they are physically or mentally ready to do 
so. Early marriage exposes them to a range of risks including high-risk pregnancies and births, 
intimate partner violence, and the transmission of HIV (Chandra-Mouli et al, 2015).  In 
emphasizing the dangers of early marriages a Report on Programme of Action of the 
International Conference on Population and Development (2014) has shown that about 70,000 
adolescents in developing countries die annually of causes related to pregnancy and childbirth. 
Nine of 10 births to girls below age 18 occur within early marriage. Researchers have found 
that girls who become pregnant before age 15 in low- and middle-income countries have double 
the risk of maternal death and obstetric fistula than older women (including older adolescents), 
in particular in sub-Saharan Africa and South Asia.  

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Gender norms shape the lives of adolescents. These social expectations cover attitudes towards 
marriage and fertility, including, in some societies, early marriage as it has been noted before, 
particularly for girls, and in others proof of fertility before unions are formalized. Expectations 
for male adolescents may include gaining sexual experience as well as proving their fertility. 
Furthermore social norms that condone violence against women or girls put adolescent girls at 
risk of pregnancy and sexually transmitted infections, including HIV.  
VI. 
Consequences of inadequate knowledge of sexual and reproductive health 
information and risky sexual practices among adolescents  
A study conducted by Chandra-Mouli et al (Ibid,op cit) revealed that while adolescents 
generally enjoy good health compared with other age groups, they face particular health risks, 
which may be detrimental not only for their immediate future but for the rest of their lives; and 
this therefore calls for a school based sexuality education program to introduce to young 
adolescents sexuality education so as to secure their future. Many adolescents become sexually 
active at an early age when they do not know how to avoid STIs and unwanted pregnancies. It 
has as well been noted that lack of or inadequate reproductive health knowledge is one of the 
factors indicated in literature contributing to early and unprotected sex and other risky 
adolescent sexual behavior (Slap et al, 2003) 
 
It has further been noted that lack of knowledge about sex and family planning and the lack of 
skills to put that knowledge into practice put adolescents at risk for pregnancy. Effective 
sexuality education is lacking in many countries, including Uganda.  The one global measure 
of coverage related to sexuality education indicates that only 36% and 24%, respectively, of 
young men and young women aged 15–24 years in developing regions have comprehensive 
and correct knowledge of HIV/AIDS (WHO, 2012) 
 
The effectiveness of a comprehensive Student led ASRH school model 
In the view of supporting a school based sexuality education model, one review of risk and 
protective factors for ASRH in low- and middle-income countries found out that adolescents 
currently in school are less likely ever to have had sex compared with those who leave school 
early. Furthermore, the more years adolescents remain in school, the greater the chances that 
modern contraceptives would be used (Svanemyr et al, 2015) 
 

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This student led intervention reflects on the views proposed by Villa-Torres et al (2015) on 
youth’s right to participation and promotion of youth leadership in the development of sexual 
and reproductive health policies and programs express how SRH programs for youth and youth-
led organizations have flourished and that a handful of studies have documented and evaluated 
youth participation as a component of SRH programs, and ultimately, a key component to 
achieve program outcomes. The assumption is that university students, are young people who 
can easily relate with the young adolescents in primary schools and that a higher level of trust 
will allow open discussions of sensitive topics, allowing for information to flow in both 
directions. While university students are about 10-15 years older than the primary school 
children, they have an advantage because they are still quite young and may more easily relate 
to the young children than adults. This arrangement of having the sexual and reproductive 
health education led by university students  may be considered to be alternatives to the top-
down adult-led health promotion interventions because they viewed to led to promotion of 
better communication with young people and ensure their effective participation 
 
VII. 
Research Setting  
The research will focus on Mbarara District in South western Uganda. The study data will be 
collected from selected primary schools in Mbarara District South-Western Uganda. South 
Western Uganda is which comprises of 9 districts including Mbarara District where the study 
will be conducted. Mbarara District consists is subdivided on 02 Counties and 01 Municipality 
as the local government administrative units. The Counties and the Municipality are sub-
divided into of 14 sub-counties and 4 divisions respectively. A Sub-county is 3rd lowest local 
government structure of a district while a Division is equivalent to a sub-county but for 
municipalities and cities. According to the 2015 District Education reports, Mbarara has a total 
number of 248 primary schools with an estimated primary school enrolment of 80,924 (Mbarara 
District Local Government 2015). The project will be implemented in the 6 sub-
counties/divisions  closest to the MUST campus.  
 
VIII. Methodology  
The study will use a cross-sectional study design to be able to examine the impact of a 
comprehensive sexual and reproductive health education program in mitigating young 

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adolescents SRH risks. A Multi-stage stratified sampling method will used to determine sub-
counties and schools for the study. With an estimated 123 pupils within P5-7 per school based 
on a 35% average estimate (UDHS 2011), a total of 33 Schools will be considered within the 
18 sub-counties/divisions of Mbarara district. A pilot study will be conducted prior the baseline 
study to test the survey and estimate intra-cluster correlation for the sample size calculation. 
The pilot study will be conducted in 8 schools,  in urban area and  in a rural area. The selection 
of participating schools will be determined by acceptability of school to the programme. 
Study procedures  
- 
Year 1: baseline assessment (IR1) and development of the intervention (IR2) 
(primary/grade 4, 5, 6 and 7) 
- 
Year 2-3: implementation and monitoring of the intervention (IR3) (primary/grade 5, 6 
and 7) 
- 
Year 4: effectiveness study (IR3) and dissemination (IR4) (primary/grade 6 and 7) 
Intermediate results: 
IR1 and IR3 are distinct research activities and will be elaborated further. 
IR1: The gaps in SRH education are assessed: 
The baseline assessment consists of three main parts: 
- 
A survey for the study population. This survey has the objective to assess the current 
state of SRH knowledge, attitudes towards SRH and SRH behaviors. The survey will 
also include questions on current sexuality education, on where the study population 
seeks and finds information on SRH and their preferred sources for and methods to learn 
about SRH. We will do this survey among students from grades 5, 6 and 7. The 
responses of students from grade 4 will be used as a baseline for the longitudinal 
effectiveness study (see further). 
- 
A qualitative assessment of perceived barriers to implement a comprehensive SRH 
school model. We will interview the main stakeholders: young adolescents, their 
parents, teachers, school principles, community leaders, religious leaders, district health 
and education officials, and policy makers. 
- 
A desk study on current initiatives on SRH for early adolescents in Uganda, sub-Sahara 
Africa and other countries. It will also study the Ugandan laws and regulation on this 
and related topics. 
 

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IR2: Develop an interdisciplinary ASRH school model with integrated gender-perspective 
for young adolescents in primary schools. 
Information generated from the SRH Education gap assessment will serve as the basis for the 
development of a gender-sensitive comprehensive SRH school model based on an explicit 
theory of change. The technical content and the social ramifications of said content will be 
constructed and overseen by faculty and students from both the medical and social science areas 
in a comprehensive approach geared toward creating a socially and gender sensitive yet 
medically impactful curriculum. 
 
We will set-up a community advisory board that includes all main stakeholders that will be 
consulted to provide advice and input in the process of development and implementation. 
Before implementation, the curriculum will be presented and screened by students, parents and 
teachers including the community advisory board to ensure appropriateness and applicability 
of the curriculum. The premise behind such a collaborative approach is that offering all stake-
holders a platform for offering their input on sexual and reproductive health is necessary to 
ensure sustainability and social acceptance. Establishing a curriculum will allow for continuity 
in application of the subject material across schools and districts. 
 
IR3: The effectiveness and enabling/hindering factors in the development and 
implementation of the ASRH school model are studied 
We make a distinction between two research methods in the IR: identifying enabling/hindering 
factors through process analysis and studying effectiveness using a cluster-randomized design. 
- Identifying enabling/hindering factors 
The project includes close monitoring of the development and implementation of the 
comprehensive SRH school model. Often effectiveness studies of comprehensive SRH 
education find little impact of their efforts, and development and implementation issues are 
often pointed to as the reason for this limited effectiveness. Nevertheless the latter issues are 
hardly never studied independently. 
 
We want to fill this void by performing a process analysis of the development and 
implementation of the comprehensive SRH school model. All steps in the development will 
be clearly documented. The research team members will develop monitoring sheets that keep 
track of the implementation of the project. The monitoring sheet will be filled by the local 

14 
 
research team based in Mbarara and on a monthly basis will interview the a selected group 
of participating students (educators – university students, and the leaners – primary school 
students) and teachers to respond to a set of monitoring questions on the process of the 
program. Furthermore, we will perform interviews and focus group discussions with the 
project coordinators, implementers and other relevant stakeholders to gain insights in their 
perceptions of the ASRH school model, its strengths and weaknesses. 
 
- Effectiveness study 
The effectiveness of the project will be studied using a cluster-randomized pre-test post-test 
design. We will study whether the changes that have taken place of a two-year 
implementation of the ASRH school model are different in the intervention and control 
schools. This will be done using the same questionnaire as in the baseline study. The main 
outcomes are SRH knowledge, attitudes towards SRH (including gender norms) and SRH 
behaviours. Furthermore, the survey will include additional questions to assess the students’ 
appreciation of the ASRH school model. 
The intervention  
The intervention for the study will be a university student led delivery of comprehensive 
sexuality education (CSE) modules in 15 primary schools in rural and urban setting in a 
period of one year. The modules will be developed in consultation with the existing upper 
primary school curriculum for Uganda, the international guidelines on sexuality education 
(UNESCO and UNFPA). They will be carefully reviewed by experts on the study team as 
well as approval from a community advisory board comprised of community and religious 
leaders, teachers and policy makers from ministry of education and health. 
 
 
The list of modules will include 
1) Introductory modules to facilitation 
 School entry process 
 Facilitation skills 
 Adolescent development 
 Values clarification 
2) CSE core modules 
 

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CSE core modules 
11 
Puberty 
22 
Relationships and emotions 
33 
Decision making 
44 
Self esteem 
55 
Know your rights 
66 
Crossing the line (sexual violence and reporting) 
77 
Being a boy or a girl (Gender and Sexuality) 
88 
Reproduction 
99 
Sexually transmitted diseases 
1010 HIV/AIDS and Stigma 
1111 Sexuality and media 
 
Delivery of modules 
University students offering programs in Bachelor of gender and applied women heath, 
Bachelor of medicine and surgery, Bachelor of Nursing Science and Bachelor of Community 
Planning and Deveopment will apply as volunteer  student educators. An advertisement for 
student educators was put on Mbarara university website on (http://www.must.ac.ug/news/call-
young-adolescent-sexual-and-reproductive-educators) on 7th March 2016 
IX . Sample Size Estimation 
School selection, sample size estimation and school entry processes 
School mapping; In December 2015, researchers accessed lists of all schools in Mbarara district 
from the Mbarara district Education office. This list had contacts of head teachers and 
enrollment in schools. A team of field assistants visited schools and called head teachers to 
update the school enrollment in February 2016.  
A pilot survey was conducted in March 2016 and results were used to estimate the design effect 
and intra class correlation required sample size for the cluster randomized trial. A 
total sample size of 846 was determined, to measure a difference of 10% between groups 
(reference 50%) with a power of 90%. With an estimated drop-out rate of approx. 20% we opted 

16 
 
for a total sample size of 1100 students.  A sample of 1100 pupils was needed from 33 schools 
(clusters). Schools were selected by a weighted excel selection system randomly from a list of 
220 schools in urban and rural areas of Mbarara district having eliminated schools which did 
not have upper classes. A local statistician assigned schools randomly to intervention and 
control arms. Finally 15 schools were selected as intervention schools. Only 2 schools of the 
15 are in the urban area. 
Field workers visited intervention schools with letters drafted by the principal investigator 
asking for permission to having the training programs in the schools and their commitment to 
oversee the training activities in the schools. All the head teachers in the 15 schools confirmed 
participation and signed the letters of acceptance. They were further invited for a joint meeting 
with the advisory board at Mbarara University in July 2016 
 
 
X. Analysis 
The qualitative data will be transcribed and if necessary translated into English. Analysis of the 
qualitative data will be done by two independent researchers using a coding tree that was jointly 
developed after preliminary analysis. The analysis will be done in ATLAS TI.  
 
Analysis of outcomes for effectiveness of the intervention 
Statistical analyses will be conducted using Stata® (College Station, Texas, USA). All 
outcome variables will be analyzed as ordinal categorical variables, with the exception of 
sexual behavior which was analyzed as a binary variable. An interaction variable will be 
created using the round variable (baseline vs endline) and study arm variable (intervention vs 
control). We will use an ordered logistic regression to compare differences in the change from 
baseline to endline between the intervention and control arms, also known as the “difference 
in differences” method Outcome measures 
Sexual and Reproductive Health Knowledge  
SRH knowledge was measured based on knowledge of puberty, HIV/STIs and pregnancy 
prevention. This included knowledge on how HIV/AIDS can be acquired (score 0-4), types of 
common Sexually Transmitted Infections (score 0-4), knowledge of pubertal changes in boys 

17 
 
(score 0-6.) and in girls (score 0-7), and knowledge about ways to prevent pregnancy (score 0-
4).  
Sexual Wellbeing and Attitudes   
Self-esteem scores were estimated using the Rosenberg (1965) self-esteem scale.  Body image 
scores were estimated using 5 of the 6 items of the Body Image States Scale (BISS-6). Gender 
equitable norms scores were estimated using 11 items. Six of these items were adapted from 
the Attitudes towards Women Scale for Adolescents (AWSA) and 5 items were developed to 
suit the respondents’ age and the Ugandan context.  
Sexual Behavior  
Sexual behavior was defined as experience with consensual heterosexual intercourse. Owing to 
the fact that we were dealing with very young adolescents, interviewers selectively asked 
questions about sexual activity to only participants who reported that they had been to a private 
place with a peer of the opposite sex. RAs defined sexual activity for pupils using simple, age 
appropriate terms. Sexual behavior was then classified using a binary yes/no question regarding 
engagement in sexual activity prior to the study or within the intervention year.  
Other variables 
We assessed relevant pupil characteristics including age, gender, socio-economic status, 
orphanhood status and truancy. A socio-economic score was developed based on household 
water source, distance from water source, household possessions and pupil possessions 
including shoes and pairs of school uniforms, as we described previously. We also assessed 
truancy, which was defined as missing school for any reason other than illness. We selected 
individual and interpersonal variables that could affect the key outcomes among very young 
adolescents.   
 An interaction variable was created using the round variable (baseline vs endline) and study 
arm variable (intervention vs control). We then used an ordered logistic regression to compare 
differences in the change from baseline to endline between the intervention and control arms, 
also known as the “difference in differences” method. We will conduct both a univariate 
analysis and a multivariate analysis controlling for key covariates, including age, gender, school 
location (rural vs urban), truancy, and orphanhood. We will conduct a second multivariate 
analysis splitting the groups by gender, to assess whether there was a difference in the treatment 
effect between boys and girls. 

18 
 
 
 
 
XI. Ethical Issues  
There are no medical risks in this study; the main anticipated risk is an increased discussion of 
sexuality and adolescent vulnerabilities which will increase young adolescent’s awareness of 
matters that are not commonly discussed in their immediate communities. Participation in the 
study is voluntary and participants will be given a chance to refrain from answering questions 
they do not feel comfortable with and will be at liberty to withdraw from the study. Written 
informed consent will be obtained from the parents and guardians or caretakers of all the young 
adolescents in the target class before their selection and the purpose of the study will be 
thoroughly explained to the parents in the form. However, because of the difficulty of obtaining 
written informed consent from each parent/guardian, the approved procedure for obtaining 
consent will be in such a way that the head teachers will consent on behalf of adolescents whose 
parents will not have been reached and those whose parents who will not have returned the 
signed consent forms.  
 
While all students in the upper primary of the selected schools will participate in the survey and 
intervention activities, all data will kept anonymous i.e. codes not names will be used to for 
data entry. There will not be any financial benefits for participation in the study, all benefits are 
educational.  
 
If intervention prove effective, it will be integrated in the students’ outreach activities of the 
university to allow implementation in other schools in the country.   
 
The study will seek ethical approval of the South host Institution – Mbarara University of 
Science and Technology and the Uganda National Council of Science and Technology. The 
study will abide by the ethical standards of the two institutions plus Ethics Committee of Ghent 
University Hospital and Free University of Brussels. 
 
XII. Expected outputs and Dissemination   

19 
 
The first tangible output of the project is construction of data base on primary SRH education 
practices, enabling factors and gaps.  
 
The second output will be a gender sensitive and comprehensive SRH school health model and 
an established university led SRH curriculum for young adolescents.  
 
 
We expect that this project will generate enough data and findings for two doctoral 
dissertations. One will be done within the Faculty of Medicine and Health Sciences at Ghent 
University, the other one in the Faculty of Arts and Philosophy of the Free University of 
Brussels. Both candidates will contribute to the further strengthening of Mbarara University’s 
SRH related research capacity.  
 
XIII. Selected Literature Sources   
Baryamutuma, & Baingana, (2012). Sexual, reproductive health needs and rights of young 
people with perinatally acquired HIV in Uganda. African health sciences, 11(2). 
 
Cash TF, Fleming EC, Alindogan J, Steadman L, Whitehead A. Beyond body image as a trait: 
The development and validation of the Body Image States Scale. Eating Disorders. 
2002;10(2):103-113. 
 
Chandra-Mouli Venkatraman,  Svanemyr Joar,  Amin Avni , Fogstad Helga, Say Lale,  Girard, 
Françoise and Temmerman, Marleen. (2015). Twenty Years After International Conference on 
Population and Development: Where Are We With Adolescent Sexual and Reproductive Health 
and Rights? Journal of Adolescent Health 56 (2015) 1- 6 
 
Darabi L et al., Protecting the Next Generation in Uganda: New Evidence on Adolescent Sexual 
and Reproductive Health Needs, New York: Guttmacher Institute, 2008. 
 
Denno, Donna M, Hoopes, Andrea J & -Mouli, Venkatraman Chandra.(2015). “Effective 
Strategies to Provide Adolescent Sexual and Reproductive Health Services and to Increase 
Demand and Community Support” in Journal of Adolescent Health 56 (2015) 22- 41. Society 
for Adolescent Health and Medicine 
 
Haberland N. and Rogow D. (2013) “Comprehensive sexuality education”, background paper 
prepared for an expert group meeting on adolescent sexual and reproductive health, held at 
Greentree, New York 
 
Hilary Homans, Melody Niwamanya, John Ssekamatte-Ssebuliba & Hector Tibeihaho. (2013). 
Government of Uganda/United Nations Joint Population Programme Mid-term Review. Center 
for Sustainable International Development  
 

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Galambos NL, Petersen AC, Richards M, Gitelson IB. The Attitudes Toward Women Scale for 
Adolescents (AWSA): A study of reliability and validity. Sex roles. 1985;13(5):343-
356. 
 
Gertler PJ, Martinez S, Premand P, Rawlings LB, Vermeersch CM. Impact evaluation in 
practice: World Bank Publications; 2016. 
 
Medley A, Kennedy C, O’Reilly K, Sweat M. (2009). Effectiveness of peer education 
interventions for HIV prevention in developing countries: A systematic review and meta-
analysis. AIDS Educ Prev 21:181-206. 
 
Nyakato, Unmet Sexual and Reproductive Health of University Students in Uganda; 
Saarbrücken., Lambert Academic Publishing, 2013  
 
Report on Programme of Action of the International Conference on Population and 
Development. (2014). General Assembly- Report of the Secretary-General 
 
Rosenberg M. Rosenberg self-esteem scale (RSE). Acceptance and commitment therapy. 
Measures package. 1965;61:52. 
 
Slap G, Lot L, Daniyam C, Zink T, SUccop, P. (2003). Sexual behavior of adolescents in 
Nigeria: Cross Sectional Survey of Secondary School Students. BMJ, 326 (7379). 
 
State of World Population (2013).  Motherhood in Childhood — Facing the Challenge of 
Adolescent Pregnancy (United Nations publication 
 
Svanemyr Joar, Amin Avni,. Robles Omar J & Greene, Margaret E. (2015). Creating an 
Enabling Environment for Adolescent Sexual and Reproductive Health: A Framework and 
Promising Approaches. Journal of Adolescent Health 56 (2015) 7-14 
 
UBOS (2012). Uganda Demographic and Health Survey 2011. Kampala, Uganda Bureau of 
Statistics and ICF International. 
 
Villa-Torres Laura & Svanemyr Joar. (2015). Ensuring Youth’s Right to Participation and 
Promotion of Youth Leadership in the Development of Sexual and Reproductive Health 
Policies and Programs. Journal of Adolescent Health 56 (2015) 51-57 
 
WHO. (2012). “Early marriages, adolescent and young pregnancies” Report by the Secretariat 
at Sixty-Fifth World Health Assembly