Demographics characteristics of the participants
Two hundred and sixty girls participated in the survey and of them twenty-three girls participated in the interviews as well. The mean age of participants was 15.9 (SD 0.11, 95% CI 15.6, 16.0). The highest number of the girls were born in DR Congo (29.6%) and the lowest number came from Kenya, with only 1 participant out of the 260. The majority (about 37%) of the participants had been living in Uganda for more than 5 years or between 1 and 3 years (28.9%). Few of them (0.7%) could not recall or relate the duration of stay in Uganda and also a minority of them (4.2%) were staying in Uganda for less than a year. Seventy-one percent of girls had completed at least primary education and about 26% of them had completed secondary education. A total of 63.5% of girls were also currently in school. The demographic characteristics of the participants has been presented in Table 1.
Sexual and reproductive health knowledge among girls
We assessed the knowledge of SRH topics, e.g. ways of HIV transmission, STIs and family planning via survey. A total of 23 out of the 260 (8.8%) participants did not know about the ways of acquiring HIV and 30 of them did not know about the method of HIV prevention. Similarly, 41 (15.7%) of the participants could not name any of the STI’s and 36 (13.8%) did not know about a single method of contraception. Among the girls knowledgeable about HIV acquisition, sexual intercourse with infected person was the most popular reason (85.8% of them had chosen this option). In the same manner, 80.4% of girls selected abstinence as a way of preventing HIV transmission. The SRH knowledge of the girls described through the four components has been presented in Table 2.
A multinomial regression analysis showed that age, education level and teachers/school as a main source of SRH information were associated with better SRH knowledge. Results are presented in the Additional file 1.
These quantitative findings were confirmed by individual interviews. With respect to the route of HIV transmission, the girls frequently talked about sexual intercourse and sharing of sharp objects with an HIV infected person as risk factors. The other routes, such as mother to child transmission or breastfeeding, were not much discussed by them:
“… don’t have sex or play with someone who has it [HIV]. Because if you have sex with someone who has HIV, it can be passed on to you. And still if you fight with an infected person, you may scratch him or he may scratch and your blood can easily mix. ”(15 years old).
Similar results were seen for the ways of HIV prevention. The majority of girls during the interviews mentioned abstinence as an important method for preventing HIV acquisition or pregnancy. For the girls that knew more than one way of prevention, the next most well-known method was by the use of condoms.
The knowledge of girls about STIs was limited to HIV and syphilis for a vast proportion (80 and 31% of girls respectively). Some of them also talked about Hepatitis B and Neisseria Gonorrhoea, however, the symptoms of STIs were not clear to the girls.
The contraception methods often mentioned by girls were abstinence and condom use. Other than these methods, injection and pills were mentioned by few girls who had knowledge about two or more contraceptive measures:
“The methods of preventing pregnancy are like this: when you are still a student, you must abstain from sex. Then when you are a woman and you want to have sex without producing, you can use pills, injections and self-control.” (17 years old).
Misconception about family planning methods was also present:
“… I cannot use family planning methods because they are not good. They can affect life.” (17 years old, not sexually active and has not used contraception yet).
Menstrual hygiene and commodities
Out of the 93% of participants that had already experienced menstruation, the average age for the start of menstruation was found to be 13.4 years (95% CI, 13.2, 13.6, SD 0.7). While most of the girls began menstruation at either 13 or 14 years, one of them had at nine and some at 16. A total of 78% of menstruating girls had access to disposable pads (distributed by the UNHCR) and used them followed by cotton cloth (made from rags) - 18%. There was also one case of using plant leaves during menstruation.
The challenges in accessing menstrual hygiene products were also discussed in the interviews. The participants reported that the UNHCR distributed 5–6 packets of pads per women on an average of 6 months which sometimes even had to be shared with other female family members. When lacking pads, the adolescents used old clothes, and these were often reused after washing:
“Sometimes when it’s not there [pad], we use clothes.” (16 years old).
“For me here, when I get money, I buy some pads and, when I fail to get money, I tear clothes and use them.” (19 years old).
“We hang them [clothes] there outside. And then sit around to keep them until they dry, or else other people will steal them.” (16 years old).
A total of 43% of the menstruating girls missed school during their menstruation due to multiple reasons. The main reason was pains during menstruation – named by 74% of girls. The girls were also afraid of staining (22%) and some had no product to manage menstruation (16%). Minority of them (2.8%) were afraid of being teased and the same proportion were also prevented from attending schools because of religious barriers or social taboos related to menstruation. During the interviews, the participants were frequently mentioning that they missed schools mainly because they had either severe pains or bleeding during the menstruation. This statement is also supported by the fact that one of the most common reasons to access health facilities was to seek help for menstrual problems.
Sources of information and access to SRH services
For many participants (38.5%), the most important source of SRH information was schools or teachers. The second most important source (34%) was parents or guardians. Television, internet, books or magazines and male relatives were not considered as an important source by any of the girls. Although radio was mentioned as an important source of information by few of them (1.5%), none of them preferred radio as a source of SRH information. The important and preferential sources of SRH information by the participants ordered by ranking has been elaborated in Table 3.
During the interviews, girls mentioned that even though their mothers were obviously the first and the closest person they could approach for sharing and discussing the SRH problems, they hesitated to do so. Some of them because of shame and some of them due to fear. The discussions with their mothers were limited to menstrual problems and its management. Mothers also frequently advised them to abstain from sex until they were married without discussing other topics, such as contraception. The participants stated that they sometimes discussed HIV and pregnancy with their friends:
“I talk to my mother, of course, but mostly I don’t share with my mother because I feel shy. So, I have to ask friends who have experienced those things. I can consult them about how you do abortion, prevent HIV and ways through which one can acquire HIV. That’s what I ask them.” (17 years old).
With this regard, the schools and teachers were the major source of SRH information for them. Teachers explained girls about menstruation hygiene and mostly promoted abstinence:
“… also teachers always teach us how to use pads while having periods.” (15 years old).
“… .at school they [teachers] taught us to abstain from sex until we finish our studies and get married.” (19 years old).
While did sometimes discuss other SRH topics, such as condom use and STIs, coverage of these topics was seen as poor or unsatisfactory by the students. One of the participants in the interview also mentioned that she learned about contraception methods by overhearing the women in the neighbourhood talking about them.
Access to health services among refugee girls was also found to be low with a total of 68.8% of participants who had never visited health centres to seek SRH services. Among the remaining 31.2%, the reasons for a visit were mostly HIV testing (22.7%) and menstrual problems (20.2%). About 83% of girls who ever visited a health care facility were willing to come back in the future. Some girls who did not want to return to the facilities pointed out the lack of privacy and mentioned the lack of resources, e.g. medicines in the centres due to which their problems could not be solved by the health workers. The girls also mentioned distance to the centres and mistreatment (e.g. judgments and impoliteness) by the health personnel as reasons for non-return.
When discussing the access to SRH services during qualitative interviews, the majority of girls did not know where to seek care related to SRH and were not aware about the location of the health centres. This could also be a reason for low number of visits to the SRH services. Interviewed girls who have already been living in the camp for longer had more knowledge about the existence of such services. Even then, they mentioned the distance to the facilities, lack of privacy and lack of health personnel as barriers to seek care for SRH problems. The issue of privacy was not only relevant to the health centres but also to schools, e.g. when girls wanted to discuss SRH aspects with teachers they were discouraged to do so knowing that they might share this information with others:
“… .some of them [teachers] are tough. Some of them [teachers] when you tell them some problems of yours they also go to speak with fellow teachers.” (16 years old).
Sexual experiences including pregnancies and forced intercourse
Out of the total 260 female adolescents, 30 reported to be sexually active. The mean age for having the first sexual intercourse was 16 years (95% CI: 15.2, 16.8; SD 0.3). Among the sexually active girls, some (3) had intercourse between the age of nine and 12. A total of 36.6% of sexually active girls had forced intercourse and 23.4% of them had transactional intercourse. For the majority of the girls (46.7%), the partner was 1–5 years older. About 6.7% of them even had partners who were 10 or more years older than they were.
Among the 30 sexually active girls, a total of 70% of girls reported not using a condom the first time they had sexual intercourse. About 6.7% of them had used pills and the rest did not use any methods of contraception. A total of 46.7% of sexually active girls had been pregnant and for all of them, the outcome was a live child. But the pregnancy was desired only for 42.8% of those pregnant girls. The sexual experiences of the girls have been summarized in Table 4.
When the sexual experiences in the past 3 months were considered, only 36.6% of girls were sexually active according to the survey. Among them 90.9% had single partner. The rest could not recall the number of partners. For 81.8% of them, the partner was a steady partner (boyfriend). However, only 18% of them reported using condoms during the last 3 months. About 63.6% of them did not know the HIV status of their partners and the rest were confident about the partner being HIV negative. Although not used, 54.6% of girls said to have discussed contraception with the last partner.
During the interviews, the participants often mentioned the fear of getting pregnant, as pregnancy before marriage was unacceptable in the society. This would cause a girl to be excluded from the community and even get expelled from school. This was a major factor that lead girls to abstain from sexual intercourse:
“… some people in our community just chase a girl who becomes pregnant out of her home even if the parents are not aware of the issue …” (16 years old).
“… she was dismissed from boarding section [at school] … they expelled her.” (16 years old).
The girls in the refugee camp were also victims of forced sexual intercourse. As discussed in the interview, some were victims of sexual violence during the war in their home country, some of them were raped in the camp itself and some on the migration way to the camp:
“In Burundi there was a war, they would come and find you in the house, they mistreat [rape] girls and ladies and leave your father observing and later kill you … on the way we met people who wanted to rape us …” (19 years old).
“… on the way, we met thugs, they run after us and raped all of us … I came here with the pregnancy of my child which I acquired from Congo through rape.” (19 years old).
During the interviews, it was found that not only forced sex but also coerced sex was prevalent in the camp:
“… I had nothing to do, the man was very strong and older than me.” (18 years old).
“… men come to trick us and lie that they love us and may end up impregnating us.” (19 years old).
Transactional sex, which was prevalent among adolescent refugees, was also discussed in school as mentioned by a participant during the interviews. She mentioned that in school they are made aware that they should avoid transactional sex:
“We learn that students should avoid free gifts from men. ” (17 years old).
Not a majority of them used condoms or other contraceptives the first time they had sexual intercourse. This was, as stated by the participants during the interviews, because of the fear of the partner or because the partner forced them to bear a child:
“… I feared him and I didn’t use any contraceptives to stop pregnancy because of the fear.” (18 years old).
Female genital mutilation
Female genital mutilation (FGM) was seen to be prevalent in this population. About 10% of the participants of the study had been circumcised. They were mostly from Somalia (21), DR Congo (3), Uganda and Rwanda (3). The mean age when the circumcision took place was 7.3 (95% CI: 5.4, 9.1). For 44.4% of them, their mother made the decision that they would be circumcised. Some of them even reported that the decision was made by a close friend (7.4%).
The interviewers also talked to the girls about their experiences with FGM. The girls could relate very little of their experiences since for the majority, it took place when they were very young. But the consequence of the circumcision lies with the girls and they are constantly being affected by it. They complained of severe problems and pain during their menstruation. Not only the problems during menstruation, but some of adolescents also have difficulty with urination because of the circumcision. Despite all these difficulties, some of girls accept FGM as a part of their tradition:
“…while in the menstruation periods they make me feel pain. I can urinate little, little not very well … but I am happy with it because all my friends, my mother, my sister, my aunts, we are all the same. So I don’t feel like it’s only me.” (18 years old).