Brent Wolff

Negotiating reproductive outcomes in Uganda

In Uganda, the Negotiating Reproductive Outcomes study is investigating the nature of negotiation within sexual unions. Data were gathered from focus groups held in the Masaka and Lira districts during February and March 1995 and during surveys of women aged 20-44 and their male partners carried out from October 1995 to February 1996. The data suggest that much of the bargaining and negotiating that occurs is indirect and nonverbal and, thus, leads to a great deal of misinterpretation. Even direct communication is fraught with complexity, misinterpretation, and mistrust. These results indicate that male partners are important in influencing the reproductive attitudes and behavior of women and that further work should be undertaken to understand the roles of various actors in reproductive decision-making.

Gender and decision-making over condom use in two districts in Uganda.

Based on a survey of couples in long-term unions in Masaka and Lira districts in Uganda, we critically examine the role of gender inequality in the domain of decision-making about fertility and sex in the discussion and use of condoms. First, we document the sexual context and process of condom negotiation from the perspectives of women and men. Next, we test the hypothesis that increases in the relative influence of women, compared to their male partners, in decision-making about sex and fertility should enhance the likelihood of discussion and use of condoms. The result point to barriers that exist for both men and women but show a clear disadvantage for women. They also suggest that, for both partners, a sense of control over fertility has a positive effect on condom use, and that the effect of womens empowerment does not seem to diminish the effect of mens empowerment.

Is sexual risk taking behaviour changing in rural south-west Uganda? Behaviour trends in a rural population cohort 1993–2006

Objective: To describe sexual behaviour trends in a rural Ugandan cohort in the context of an evolving HIV epidemic, 1993–2006. Methods: Sexual behaviour data were collected annually from a population cohort in which HIV serological surveys were also conducted. Behaviour trends were determined using survival analysis and logistic regression. Trends are reported based on the years in which the respective indicators were collected. Results: Between 1993 and 2006, median age at first sex increased from 16.7 years to 18.2 years among 17–20-year-old girls and from 18.5 years to 19.9 years among boys. Both sexes reported a dip in age at sexual debut between 1998 and 2001. One or more casual partners in the past 12 months among men rose from 11.6% in 1997 to 12.7% in 2004 and then declined to 10.2% in 2006. Among women it increased from 1.4% in 1997 to 3.7% in 2004 and then reduced to 1.4% in 2006. The rise in casual partners between 1997 and 2004 was driven mainly by older age groups. Trends in condom use with casual partners varied by age, increasing among those aged 35+ years, declining in the middle age groups and presenting a dip and then a rise in the youngest aged group (13–19 years). Conclusion: Among youth, risky behaviour declined but increased in the late 1990s/early 2000s. Among those aged 35+ years, condom use rose but casual partners also rose. Several indicators portrayed a temporary increase in risk taking behaviour from 1998 to 2002.

Money men and markets: economic and sexual empowerment of market women in southwestern Uganda.

Market trading requires access to cash, independent decision‐making, mobility and social interaction. This study sought to explore whether market work empowers women with respect to spending decisions and negotiation over sex and condom‐use. A semi‐structured questionnaire was administered to 212 market women; and 12 focus group discussions and 52 in‐depths interviews were conducted among market women in southwestern Uganda. Market women reported high levels of independence, mobility, assertiveness and social interaction. Access to cash was not synonymous with control over it, however. Spending decisions were limited by mens ability to selectively withdraw finances for expenditures central to womens concerns including household and childrens needs. Trading in markets earns women masculine labels such as kiwagi, characterized variously as independent, rebellious and insubordinate. Earning money does not change expectations of correct behaviour for wives, making it difficult for women to initiate, deny sex or ask for condoms. Independence and income from market work may make it easier for women to enter and exit new sexual relationships. However, unable to protect themselves within partnerships, HIV risk may increase as a result.

'This is where we buried our sons': people of advanced old age coping with the impact of the AIDS epidemic in a resource-poor setting in rural Uganda

ABSTRACT Much research on the impact of HIV and AIDS on older people fails to differentiate between age groups, and treats those aged from 50 years to the highest ages as homogeneous. The ‘oldest old’ or those aged over 75 years may be particularly vulnerable through declining health and independence as a result of the AIDS epidemic, which has forced some to take on roles that younger relatives would have performed had they lived. In this paper we describe the past and current experience of eight people in advanced old age living in rural Uganda who were informants for an ethnographic study of the impact of HIV and AIDS on households during 1991–92 and again in 2006–07. The aim of the study was to understand how they had coped with the impacts of the epidemic. From the eight case studies, it is concluded that family size, socio-economic status and some measure of good fortune in sustained good health enabled these people to live to an advanced age. While we recommend that targeted social protection is important in helping the poorest among the oldest, we suggest that sustaining respect for age and experience, and ensuring that older people do not feel discarded by family and society are as important as meeting their practical needs.

ABC for people with HIV: responses to sexual behaviour recommendations among people receiving antiretroviral therapy in Jinja, Uganda.

People living with HIV who are taking antiretroviral therapy (ART) are increasingly involved in ‘positive prevention’ initiatives. These are generally oriented to promoting abstinence, ‘being faithful’ (partner reduction) and condom use (ABC). We conducted a longitudinal qualitative study with people living with HIV using ART, who were provided with adherence education and counselling support by a Ugandan non-governmental organisation, The AIDS Support Organisation (TASO). Forty people were selected sequentially as they started ART, stratified by sex, ART delivery mode (clinic- or home-based) and HIV progression stage (early or advanced) and interviewed at enrolment and at 3, 6, 18 and 30 months. At initiation of ART, participants agreed to follow TASOs positive-living recommendations. Initially poor health prevented sexual activity. As health improved, participants prioritised resuming economic production and support for their children. With further improvements, sexual desire resurfaced and people in relationships cemented these via sex. The findings highlight the limitations of HIV prevention based on medical care/personal counselling. As ART leads to health improvements, social norms, economic needs and sexual desires increasingly influence sexual behaviour. Positive prevention interventions need to seek to modify normative and economic influences on sexual behaviour, as well as to provide alternatives to condoms.

High levels of psychosocial readiness for ART in an African population at the onset of treatment

Adherence at the earliest stages of treatment is likely to be influenced by prior illness trajectories and future expectations, best captured (and addressed) before treatment begins. We examined the influence of illness trajectories and treatment expectations on psychosocial readiness to start antiretroviral therapy (ART) in Jinja, Uganda. In-depth interviews were conducted between October 2005 and April 2006 with 41 members of an AIDS support organisation on their first day of treatment. Transcribed texts were translated, coded and analysed thematically using NVIVO-7 software. Results indicated that acute fear of death and progressive withdrawal from social, economic and sexual roles narrowed focus on survival, while efficacy-enhancing experiences with septrin prophylaxis and trust in counsellors reinforced belief in HIV diagnosis and importance of adherence. Most enjoyed supportive home environments after disclosing their serostatus. Lack of money for food and transport was anticipated as the main barriers to future adherence, particularly among women. Integrating strong counselling support with ART provision helped channel the power of shared illness experience into positive motivation to adhere at the onset of treatment.

PERIOD AND COHORT DYNAMICS IN FERTILITY NORMS AT THE ONSET OF THE DEMOGRAPHIC TRANSITION IN KENYA 1978–1998

A characteristic of African pre-transitional fertility regimes is large ideal family size. This has been used to support claims of cultural entrenchment of high fertility. Yet in Kenya fertility rates have fallen. In this paper this fall is explored in relation to trends in fertility norms and attitudes using four sequential cross-sectional surveys spanning the fertility transition in Kenya (1978, 1984, 1989 and 1998). The most rapid fall in the reported ideal family size occurred between 1984 and 1989, whilst the most rapid fall in the total fertility rate occurred 5 to 10 years later, between 1989 and 1998. Thus these data, spanning the fertility transition in Kenya, support the traditional demographic model that demand for fertility limitation drives fertility decline. These data also suggest that the decline in fertility norms over time was partly a period effect, as the reported ideal family size was seen to fall simultaneously in all age cohorts, and partly a cohort effect, as older age cohorts reporting higher ideal family sizes were replaced by younger cohorts reporting lower ideal family sizes. These data also suggest that a new fertility norm of four children may have developed by 1989 and continued until 1998. This is consistent with, and perhaps could have been used to predict, the stall in the Kenyan fertility decline after 1998.