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3. Conclusions & recommendations

3.1 Conclusions
3.2 Recommendations

3.1 Conclusions

1. While youths are among the most vulnerable groups to HIV infection, they are also the most promising agents of behaviour change. Young men and women are vulnerable to HIV infection because they begin sexual activity at an increasingly younger age, tend to have multiple partners and have restricted access to information on safer sexual practices. In addition, the interplay of a wide range of factors - war and instability, the loss of appeal in agriculture as a profession, economic hardship and the absence of income-generating opportunities, the increase in drop-out school rates and alcohol/drug abuse - have contributed to the creation of a high risk environment for rural young men and women. -An increase in poverty and illiteracy, lack of opportunities, and the erosion of social values and family life education act as catalysts to high risk sexual behaviour.

2. Young women are more susceptible to contracting HIV than young men for biological, health-related and socio-economic reasons, but also because they have until recently been neglected by HIV/AIDS education interventions.

3. AIDS follows a different pattern in each village and district. Geographic and ethnic factors, agro-ecological conditions, religion, gender, age and marital status play a role in the pattern and impact of HIV/AIDS and in people's perceptions of the disease. Even within one district, two villages can have radically different agro-ecological conditions and customs that determine sexual behaviour and attitude towards HIV/AIDS. This has critical implications for the design of HIV/AIDS interventions - namely that district-specific approaches are essential.

4. Available-seroprevalence data for rural areas may not always be reliable and indicative of the spread of the disease in a given area. Districts believed to be only marginally affected by HIV/AIDS may appear so only because there are no sentinel sites or other monitoring mechanisms in place.

5. HIV/AIDS is disproportionately affecting young rural women. There are far more AIDS widows than widowers in the three districts visited. Young widows with dependent children tend to become entrenched in poverty as a result of socio-economic pressures related to HIV/AIDS. The AIDS stigma, for instance, which largely results from the prevailing stereotype that it is the women who are responsible for transmitting HIV, is undermining traditional coping mechanisms accessible to young widowed women and changing the socio-economic fabric of the extended family.

6. The assumption that 80%-90% of Ugandan men and women are aware of HIV/AIDS and know how to protect themselves does not apply to the rural areas visited, particularly not to young rural women. Myths, misconceptions, superstitions, stereotypes and stigmatization are widely prevalent in Tororo and Gulu districts. The less people know about the disease, the more negative they tend to be about HIV/AIDS-afflicted and affected families and the stronger the stigmatization. What is particularly significant is that individuals tend to blame their partners for transmitting the HIV virus, not themselves for engaging in high risk sexual behaviour.

7. In general terms, school children are better informed about HIV/AIDS than out-of-school youths; school boys are better informed than school girls; out-of-school men are better informed than out-of-school women; and older women are better informed than younger women.

8. There is a need to differentiate between school and out-of-school youths. As HIV/AIDS initiatives are already targeting school children with some success, it is most important to reach out-of-school rural youths, particularly girls. In rural areas, girls tend to drop out of school at the P3 or P4 level and do not benefit from HIV/AIDS education which begins at the P5 and P6 level. Out-of-school youths, including those who drop out, make up the majority of rural young people.

9. If behaviour change is to be effective, it should involve the youth itself in the generation of appropriate messages and should address socio-economic and cultural realities that influence sexual behaviour. Creating a forum for discussion and for interactive learning, where respect for HIV/AIDS as well as for young people's social and sexual needs co-exist, can help create an enabling environment for the generation of appropriate messages.

10. Behaviour change strategies that do not address socio-cultural norms, including early sexual behaviour, STDs, alcohol and drug abuse, bar and disco culture, ritual cleansing and wife inheritance, etc. but only hinge on sexual behaviour per se are not likely to be effective, particularly among youths. If behaviour change is measured in part in terms of changing patterns of alcohol/drug use, frequency of bar visits, etc., a more accurate picture of behaviour change would emerge.

11. Traditional norms and customs concerning wife inheritance, oral or written wills, widows' rights to land and property, etc. often tend to overrule the implications of HIV/AIDS. This needs to be taken into account when designing interventions.

12. Behaviour change is also conditional on communication, negotiation and assertiveness skills, motivation and perseverance for men as well as for women.

13. The fact that behaviour change is a continuous process and a change in lifestyle rather than an occasional exercise in self-control needs to be addressed in the design of interventions.

14. Women's socio-economic status and the breakdown of the institution of marriage in some areas, need to be addressed, in particular: alcohol brewing/distilling as a major economic activity for young rural women and the need to create alternative income-generating opportunities; bride wealth, which has become unaffordable for many young men; and the growing number of informal unions between men and women which translates into a loss of legal rights for women living with their partners outside of marriage.

15. Many young men and women, want to be tested for HIV (sometimes along with their children), but they do not have access to information and facilities. Pre-testing counselling and practical advice on how to persuade a partner to take the HIV test are key components. A major issue to be addressed, however, is transport cost, which is often prohibitively high, especially for women.

16. A strong youth programme aimed at increasing opportunities and creating choices for young people in rural areas through income-generating activities, leadership and management training, recreation, health education, and communication/negotiation skills is in itself a strategy against HIV/AIDS. This is in line with the Uganda AIDS Commission approach which specifies that "prevention activities should be integrated into mainstream health programmes and other programmes dealing with community, women and youth development."

17. As a group, youth includes children (ages 10-14), adolescents - some of whom are parents, particularly girls - (15-18 years) and young adults, most of whom are parents (19-25 years). These groups may have to be targetted separately, given the fact that their lifestyles, sexual behaviours and learning abilities differ. Childhood/adolescence, marriage and parenthood are often very close together for girls/young women. This needs to be taken into account when designing interventions.

18. HIV/AIDS is having an adverse effect on the already overburdened and under-resourced agricultural extension service. Highly qualified civil servants and technocrats are increasingly dying of AIDS and are not being replaced. In some districts, it is becoming difficult to implement agricultural programmes as a result of HIV/AIDS: extension staff are frequently attending burials. Every time there is a burial, the work week is reduced from six to three days (Tuesday, Wednesday and Thursday) as civil servants have to take Saturday, Sunday and Monday off (Friday is the official day of rest) to travel to the village and attend the burials. HIV/AIDS interventions targetting rural youths through the agricultural extension service may be ineffective, without appropriate measures to strengthen extension.

3.2 Recommendations

3.2.1 Recommendation #1
3.2.2 Recommendation #2
3.2.3 Recommendation #3

Building on the approach recommendations outlined in the Uganda National Operational Plan for STD/HIV/AIDS Prevention. Care and Support 1994-1998, the youth programme should use an integrated strategy to HIV/AIDS and target primarily out-of-school rural youths, with an emphasis on young women.

Occasions and sites where out-of-school rural youths can be mobilized include meeting places such as wells, markets, bars, and social or recreational events (weddings, funerals, football/netball matches). Out-of-school youths can be mobilized more effectively when labour demand is at its lowest, i.e. during the dry season, when they have more free time. School premises can be used for out-of-school activities during weekends and holidays.

Three recommendations are proposed for Uganda's youth programme:

3.2.1 Recommendation #1

Develop an HIV/AIDS education component (prevention and impact alleviation) integrated in the overall youth programme. The youth programme's upcoming Strategic Planning Exercise should deliberate on who will be trained to deliver the HIV/AIDS education package outlined below (youth leaders. RC youth officers, YFP office bearers, health workers, and/or youths afflicted or affected by HIV/AIDS, or a combination of the above).

The objectives of the HIV/AIDS education component will be to: a) prevent the spread of HIV/AIDS by informing youths about HIV/AIDS, empowering them with the ability to make choices; and create the necessary motivation for behaviour change; and b) moderate the impact of HIV/AIDS on those already infected and on their families.


a) Develop a Health Promotion package, which will include primary health care (safe water, water-borne diseases. Oral Rehydration Salts, etc.), nutrition,22 family planning (integrating project INT/92/P94: Integration of Population Education into Programmes for Rural Youth in Uganda), first aid and sexually transmitted diseases. This primary health care component, including HIV/AIDS, should be targeted to both women and men.

b) Communicate basic facts about HIV/AIDS transmission and prevention. Many young people have memorized the facts about HIV/AIDS but have not internalized this knowledge and are not confident with what they know about the disease. The goal should be to delay the onset of sexual activity among the under 10 year olds and promote low risk activities amongst those who are already sexually active.

22 The YFP previously had a health component consisting mostly of occasional visits from nutrition and home economics officers and targeted primarily toward the women. This component no longer exists.

Questions frequently raised during the field work, and which should be addressed by the STD/HIV/AIDS education component include:

Where did AIDS come from?

Is Africa responsible for the disease?

What is a virus? What does the HIV virus look like?

Why can an infected man/woman look healthy for a long time?

Is it unhealthy to abstain from sex? Why not?

Should a woman use the same cloth to clean herself and the man after sex?

("enkumbi" practice)

What can single men/women do when they are not married but want to have sex?

What are the alternatives to penetrative sex?

How can-one persuade a partner to use condoms?

How can a wife deny her husband sex when he is drunk and she knows he has other partners who may be infected with HIV?

How can one persuade the husband's wife that a widow should not be inherited?

Where can an AIDS widow seek advice, support and assistance?

What can one do to live longer with AIDS?

How can one help people suffering from AIDS?

c) Dispel mvths and misconceptions about HIV/AIDS. eradicating stereotypes (that it is the women who are responsible for the transmission of HIV/AIDS), superstitions (witchcraft) and prejudices.

d) Address traditional norms and practices such as wife inheritance, ritual cleansing, early sexual activity, multiple/casual partners:

e) Address the dynamics of social interaction, with emphasis on alcohol and drug abuse. Alcohol abuse is closely linked to AIDS and needs to be addressed. This may be very delicate, given the fact that alcohol brewing is an important income-generating activity for-many-households and especially women. It is clear that to combine health messages with an anti-alcohol campaign is far from simple and care should be taken not to pass judgment on alcohol and drug abusers. A more effective strategy would be to alert people to the dangers of alcohol and drug abuse, stimulate discussion, and then leave the decision to them.

f) Initiate basic legal literacy for youths and widows, informing them of their rights before the law, especially with regard to inheritance/property rights and sexual abuse. For instance, in 1990, the government of Uganda passed a bill rendering sexual abuse of children below 18 years punishable by up to 10 years imprisonment. Relevant laws should be gathered in a one or two page factsheet and discussed with youths. It should be noted that women are usually not aware of their legal rights, nor of ongoing revisions of statutes affecting them and their children. Sensitization of women's rights should not only be undertaken for the women but also for the women who need to be informed of women's rights before the law. It is also important to refer women to places where they can get legal assistance. Information on the benefits of opening bank accounts (why, how and where) may also be of assistance, particularly to women who have only girl children.

g) Empower girls to be in control of their relationships with men, to have confidence in their knowledge about HIV/AIDS, and to discuss HIV/AIDS with their partners, is critical to behaviour change. Training in negotiation skills and assertiveness should constitute an integral part of HIV/AIDS education for men and women. Discussing with young women ways in which they can say no to sex, and if forced into having sex, ways of handling it are some of the points to be addressed.

h) Promote condom use should include extensive sensitization, covering issues such as, how to raise the subject with their partners, when to use condoms, how to use them properly, how to dispose of them properly, underscoring the importance of consistent use, especially under the influence of alcohol.

i) Mobilize support for people with AIDS or people who are vulnerable to HIV/AIDS. Young widows/widowers whose families have been affected by AIDS could be involved in HIV/AIDS education and related activities and possibly given some incentives. They can also be assisted with information on how to live positively with AIDS within the community, and instructed how to make wills.


Review and revise existing health education and HIV/AIDS materials designed by a) the Uganda School Health Education Project (SHEP), where children learn about the causes and symptoms of diseases, such as diarrhoea, measles, AIDS and worms, and when to seek treatment with emphasis on prevention. SHEP also has a First Aid and a water and sanitation component; b) by UNICEF, whose Safeguard Youth From AIDS programme has an array of materials, albeit in English only. UNICEF AIDS posters found in the Primary and Secondary School Kits could be translated in local languages and disseminated to YFS; c) materials from WHO can be translated into local languages and printed free of charge (by WHO). -Materials should correspond to the learning ability and level of the three age groups.

Develop instructional materials on the socio-economic context of HIV/AIDS for rural youths in English as well as in local languages on alcohol, discos, early sexual activities, wife inheritance, condoms and STDs, in collaboration with local NGOs. Pay particular attention on messages concerning women that need to be targeted on men, including condom use, wife inheritance, forced sex. It is critical that these materials be developed locally.

Develop instructional materials on communication, negotiation, decision-making and assertiveness skills addressing problems most frequently encountered by young men and women. Imparting these skills could include role playing exercises where genders exchange roles. The issues of motivation, peer support and perseverance in every behaviour change communication also need to be built in the training.

Provide access to voluntary HIV testing and counselling by preparing an inventory of organizations providing information, advice, testing, counselling (legal and medical) about AIDS, other STDs and condoms in the district. Ensure that YFS establish links with Health and/or AIDS Information Centers, family planning clinics, AIDS-related organizations in the district so that information is continuously updated.

Explore the possibility of training and working with young PWAs to reinforce AIDS messages. ACORD has sponsored training for PWAs in order to make its AIDS sensitization seminars more effective. Working with PWAs is proving to be more successful than costly and impractical video shows most of which are in English, and it provides income to AIDS afflicted families. Uganda's youth programme could introduce the concept of organizing STD/HIV/AIDS education with assistance from youths who are afflicted or affected by HIV/AIDS. This will ensure that youths and their families affected by HIV/AIDS will not be marginalized, that PWAs will have a new purpose and role in life while also supplementing their income. Finally, it will also enhance interactive delivery of messages and make behaviour change more effective.

Initiate AIDS Drama Competition for YFS. Youths can be asked to write their own plays based on their own experience. The reason for this is that it has often been the case that even the actors of anti-AIDS drama groups do not follow the messages they deliver through their plays. By inviting YFS to write their own plays, the youths will be essentially designing their own AIDS campaign which will be personal and directly linked to the reality of the village. Stereotypes on HIV/AIDS, myths about AIDS and the attitudes of youths on AIDS could be tackled, debated and clarified. Topics such as alcohol, early sexual activity, wife inheritance, STDs and living positively with AIDS can be explored and young people can be alerted to the dangers of all these practices.

Prepare Resource Profiles for all districts where activities will be undertaken. For instance, the resources of the Ministry of Health should be tapped at the national as well as the district level. In Tororo, the DMO reported that health educators and assistant health educators engage in mobilization and sensitization, using training materials and a film van. The problem is availability of fuel, which prevents them from reaching villages off the main road. Resource profiles will also help identify the areas where technical assistance is needed.

Establish linkages between the Youth Programme and related Ministries, international organizations and NGOs involved in HIV/AIDS interventions. Collaboration between the above-mentioned agencies may be uneven at the district level, given the fact that resources are unequally distributed between the districts. Rakai has more than 30 NGOs working on AIDS while Tororo and Gulu have only a handful. In Kabarole, GTZ and ACP have launched a comprehensive programme on HIV/AIDS (though mostly focusing on urban and peri-urban areas) and there are several other NGOs working there. GTZ-ACP have considerable resources and linkages could be established with the youth programme to tap these resources. The issue of district coordination of AIDS activities also needs to be addressed. District coordination of AIDS activities is poor in Kabarole and Tororo districts (there were no District AIDS Committee at the time of field research) but good in Gulu district.23

23 In Tororo, the DMO is not in regular contact with TASO or other NGOs and is not even aware how many AIDS-related organizations are active in the district. In Gulu, there appears to be good coordination between AIDS-related activities and there is a parish AIDS Committee. The Gulu Government Hospital and ACORD are working with PWAs to sensitize villages with some success. The Office of the District Medical Officer works closely with Lacor Hospital and Gulu Government Hospital as well as with ACORD and some church groups.

Issues to be addressed in the training of trainers on HIV/AIDS/STDs include the following:

i) The need to train an equal number of male and female trainers;

ii) Sensitizing youths to HIV/AIDS/STD issues does not mean "teaching" and/or "preaching". A top-down approach may alienate youths and/or generate inappropriate messages. Rural women reported, for instance, that health workers usually talk in general terms and do not address concrete situations, such as wife inheritance, which is a critical issue for many AIDS widows. -Participatory training addressing group dynamics, gender relations, social norms, etc. may be more effective in generating appropriate messages.

iii) Ways of ensuring that trainers, in this case male and female youth leaders, will disseminate the imparted information and messages to young men and women need to be built-in the training curriculum. During the field work, it was observed that trainers often did not disseminate the imparted information to the villagers, particularly to the women.

iv) HIV/AIDS education activities should be interactive rather than pedagogical. The objective should be not simply to disseminate information but to stimulate discussion and debate that will allow boys/young men and girls/young women to internalize the information and messages generated -during the discussion. AIDS activities can be and should be creative, entertaining, educational and relevant to young men's and women's lives. Some of these activities could be initiated by the youths themselves - the more involved they are in the design and implementation process, the more effective the message is likely to be.

3.2.2 Recommendation #2

Develop a training package for agricultural extension workers, to a) raise awareness of groups vulnerable to AIDS (youths, including widows/widowers and orphans) and address the needs of each of these groups; b) sensitize agricultural extension workers to the impact of HIV/AIDS on agriculture (vulnerable farming systems) and rural development; and c) strengthen existing household and community coping mechanisms.


A three-day workshop for agricultural extension workers, consisting of the following:

a. Presentation of the different farming systems and rural settings in the districts, including:

* agro-ecological conditions
* crops
* livestock
* labour use, labour division
* off-farm activities
* community life with special emphasis on youth

Methodology: participants make presentations on their respective districts, e.g. preparation of a paper or poster

b. General introduction to the HIV/AIDS pandemic and situation analysis of the districts.

Methodology: lecture with discussion

c. How is HIV/AIDS linked to agriculture and rural development?

Methodology: Brainstorming with visualisation (participants write their ideas on cards which are then grouped and discussed)

d. Case studies

Household level: Case studies of HIV/AIDS afflicted and affected households in different farming systems, with a focus on households with young household members

Community level: Case study of an HIV/AIDS-affected community

Questions: What types of problems will appear in these households? How will the households respond to the pandemic and why? What kind of coping strategies will develop? What kind of changes occur in terms of agricultural and off-farm activities? How will rural youths respond?

Methodology: Group work with presentation and discussion; presentation of own experiences with regard to HIV/AIDS-affected and afflicted households in various districts;

Questions: How can the Agricultural Extension Service support the various coping mechanisms and livelihood strategies of different types of households, especially young widows? Which extension packages will have to be adjusted to address the impact of the disease?

Methodology: Brainstorming with visualisation and discussion

Subjects for discussion:

* recommendations for changing cropping patterns, unutilized plots, livestock (i.e. promotion of small ruminants, bee-keeping, etc.)

* labour-saving technologies

* encouragement of self-help groups, especially youth groups

* income-generating activities for youth groups

* support for community groups (older members) to assist and train orphans in agricultural skills to compensate for the loss of knowledge through the death of parents

* cooperation between the Agricultural Extension Service and active NGOs in the districts

e. Elaboration of a strategy in the form of guidelines and a workplan for the different districts to mitigate the impact of the epidemic.

Methodology: Group work with presentations and plenary meeting



Week 1

Week 2

Week 3

Week 4

Design workshop with Youth Programme (technical content, logistical modalities)


Identification of counterparts and future trainers





Preparation of workshop materials (case studies, etc.)





Conduct workshop





Revision and finalisation of workshop materials; workshop report





3.2.3 Recommendation #3

Develop interventions, activities and micro-projects to mitigate the socio-economic impact of HIV/AIDS on rural families, and particularly on youths (young widows and orphans).

These may include a variety of initiatives, such as:

i) assisting AIDS widows by leasing land from those who are not utilizing their land for Young Farmer activities, being careful, however, not to endanger -the widows' legal rights;

ii) finding ways to encourage young widows/widowers and orphans to join the youth programme by lifting membership fees;

iii) providing relief for families unable to cope with the impact of AIDS, including food, clothing and school sponsorship;

iv) training young PWAs to conduct HIV/AIDS education sessions by giving them small incentives, to be decided upon by the YFS; etc.


Develop initiatives and micro-projects at the district/village level, involving youth leaders, youths, and the National Youth Office, at the upcoming Strategic Planning Exercise of the Youth Programme.

Draft an inventory of successful income-generating activities for rural men and women and/or initiatives for AIDS-afflicted and affected families.

Establish linkages with a) the UNDP project to "Mitigate the Socio-Economic Impact of HIV/AIDS through Micro-Projects," which is operating in selected districts, including Kabarole; b) the WFP-Assisted Project 5218 "Assistance to AIDS-Impacted Households and Other Vulnerable Groups, which provides relief to AIDS-afflicted families; and c) with other NGOs working in the district in HIV/AIDS-related work, including ACORD and World Vision.

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