The App Empowering Young Women in Uganda

In Uganda, young women and girls face many sexual and reproductive health and rights (SRHR) challenges. For example, a high unmet need for contraception leads to dire consequences like unplanned pregnancies and sexually transmitted infections.

Challenges that limit provision of SRHR services to adolescents and young women include lack of privacy and confidentiality, knowledge gaps, cultural and social stigma, biased service providers, and inconvenience in accessing SRHR services despite their availability. Although there have been improvements in creating a youth-attractive environment for SRHR services and access to tools, more work is needed.

We are constantly reminded of the need to provide avenues where young people – including women and girls – can access sexual and reproductive health and rights services that are equitable, appropriate and effective.

At Reach A Hand Uganda, we help to address this need through our youth empowerment centres, and now, we have introduced the SAUTIplus app.

The SAUTIplus app is an innovative part of the SAUTIplus ecosystem,  helping to fill existing gaps in information. Uganda is experiencing a smartphone boom, with over half the population now owning one, and this number is increasing day by day.

Internet penetration in Uganda is at 41.6% – with 19 million Ugandans connected to the internet. In 2017, the Uganda Communications Commission recorded that the total number of mobile phone subscriptions was 23,529,979, up from 21,039,690 the previous quarter.

The SAUTIplus app was revamped two months ago to further engage Uganda’s high youth population and, at the time of writing, has 1,600 downloads on Google Play Store. The iOS version is in its final stages of going live.

On the app, information is available day or night. With a few taps of their phone, young women and girls can quickly find answers to their burning questions about sexual and reproductive health.

It’s the young people at Reach a Hand Uganda producing the content for the app and answering the questions – with support from the Programs and Communications departments. We understand the needs of the young women and girls and can craft our responses to reach the users in a relatable manner.

Users are able to see answers to questions other young people have asked and read tailor-made stories addressing issues faced by girls. Questions can be submitted on the website (hopefully soon to be added to the app) and the questions and answers can be viewed on either the app or website. The questions can be anonymous to maintain a safe and confidential space.

The app provides accurate information on SRHR, rather than simply promoting abstinence, which has proven an ineffective method of protecting young girls in Uganda.

The section named ‘Senga’ is a reference to a trusted relationship between a woman and her father’s sister (auntie). This relationship is commonly one where information regarding sexual and reproductive health and rights is passed on, but there can be a gap in appropriate or accurate information. This is where the SAUTIplus app comes in.

‘Senga’ provides an opportunity to view answers to questions you may have had yourself, smashing the common myths and misconceptions surrounding SRHR in Uganda. “My boyfriend says we don’t need contraception because he will pull out at the last minute. Is this a good idea?” is an example of one of the questions asked by a young girl on Senga.

The SAUTIplus app is providing a platform for women and girls to take charge of their sexual health. The knowledge the app provides is giving power to young women.

With power comes increased agency and the ability to negotiate within relationships – for example, with regards to contraceptive use to prevent pregnancy. No topic is taboo on the app. This includes menstruation and menstrual hygiene, a key SRHR challenge Reach a Hand have identified among young women in the country.

The for-the-youth attitude of the SAUTIplus app means it is an engaging platform for young people to access reliable information. Multimedia content, including photos, videos and blogs, provide a plethora of youth-friendly, easily digestible resources on SRHR.

The app is in continuous development, striving to meet the changing needs of young women in Uganda. It aims to create a positive relationship between young people and SRHR information, showing that information is a tool of power and not something to be dismissed. 

Mental Health in India’s Adolescent Girls

At ten years old, at the delicate intersection of childhood and adolescence, I lost my father.

The sudden, swift loss of a loved one left my family with a vacuum that felt insurmountable. Fear, inordinate sadness and hopelessness enveloped our home. Our South Asian family was heavily steeped in cultural norms. Showing one’s wounds to others was viewed negatively.

Crying was looked down upon, and seeking help would be an impermissible acknowledgement of weakness. Therapy was not a word in our vocabulary.

As I was expected to, I placed invisible bandages over my pain and suffering. I walked to school one week later with a forced smile pasted on my face. When asked how I was feeling, I quickly redirected the conversation, replying, “I’m okay.”

This external reticence surrounding my feelings and emotions continued throughout my adolescent years. While I experienced intermittent jolts of sadness and depression – likely as result of all that I had concealed and bottled up – I never once considered the option of therapy.

Now, as a pediatrician, I recognize the need to end the stigma and silence surrounding mental health in South Asian communities.

I have seen again and again the multi-generational consequences of mental illness, particularly depression. I co-founded Girls Health Champions, a non-profit training adolescents as peer-to-peer health educators, because I have seen firsthand that young people have significant unmet needs surrounding mental and physical health.

We know from both anecdotal and empirical evidence that adolescent depression and mental illnesses are on the rise, specifically for young women. Girls are over three times more likely than boys to experience depressive symptoms. The extent and complexity of mental illness among youth in India continues to be understudied, and the support for young people is stagnant.

Our suicide rate is a public health crisis – India accounts for 36.6% of suicides globally. Additionally, among Indian women and teenage girls aged 15–19, suicide has surpassed maternal mortality as the leading cause of death.

We have ample evidence to show that frank discussion and dialogue must start early and occur frequently. However, addressing the mental health of adolescent girls requires a thoughtful, multi-pronged strategy.

We must address cultural attitudes when approaching girls’ mental health education.

We know that South Asians, including young people, share a cultural resistance towards legitimizing mental health as a medical need. According to Dr. Nidhi Kosla, a mental health provider, South Asians “fail to report their [emotional] pain to avoiding burdening others or being seen as weak.” This might explain why many South Asians do not utilize resources such as therapy or psychiatric care, even if they are aware of them.

Additionally, in India, mental illnesses such as depression have often been equated with words such as “pagal”, or crazy. This language intensifies the shame and stigma young people experience. As a result, discussions of mental health must not only focus on awareness raising, but also on addressing and overcoming prevalent stigmas.

Mental health remains an underdeveloped and understaffed field in India’s medical practice. It is time to start building India’s mental health infrastructure.

Out of the 936,000 doctors in India, there are only roughly 4,500 psychiatrists to serve a population of 1.3 billion. In comparison, the USA, with a population a quarter the size of India’s, has 7,000 psychiatrists of Indian origin and 28,000 overall. 

India’s mental health infrastructure is also severely limited, with only 43 government mental health hospitals across all of India to provide services for the estimated 70 million people living with psychosocial disabilities.

In addition, most general practitioners and pediatricians are not adequately trained in identifying or managing mental health illnesses. These are often the people who serve as the first medical ‘touch points’ for young girls. Many providers may even hold negative attitudes towards mental health conditions themselves. Investment in training for frontline health workers is essential.

In both my experiences as a pediatrician and with Girls Health Champions, I have learned that a majority of young girls do not feel they can turn to their parents when it comes to discussing mental health-related issues. 

Parents play a critical role in providing a supportive climate around mental health.

We must educate them to have understanding, empathy, and awareness of mental health-related issues. Parents should develop the capacity to identify potential issues in their children and recognize when it would be appropriate to seek help.

I want our young people to know that it is okay to feel, to reach out for help, or even to say, “I am not okay”.

Day after day, I diagnose young girls with mental illnesses, including depression. During these visits, we often talk about the importance of removing the invisible bandages. We talk about the fact that ultimately, opening up is a sign of strength.

Obstetric Fistula is a Physical & Mental Health Priority

“It’s been three years now, I can’t wear underwear, urine is always leaking. I have developed sores on my genitals that aren’t healing because of the moisture. I dread going out in public.

The last time I went to a gathering, people distanced themselves from me because of the bad smell. I repelled them. I’m confined to this house so I can bathe each time I soil myself. My entire family believes I was cursed, they say no one has ever had a disease like mine before.”

Nyaradzai is a 19-year-old living in my community in Mashonaland, Zimbabwe. She is one of many women suffering from obstetric fistula. 

Like many others, Nyaradzai has been unaware that hers is a condition that needs medical attention. She tells me her story:

“Three years ago, I dropped out of school. I was pregnant. My parents chased me from my home, so I went to stay at my boyfriend’s house. He was still in high school too, but his parents accepted me. I stayed there for six months. 

My baby died while I was in labour. It took me 6 hours to get to the nearest clinic – I was walking because my in-laws couldn’t afford to hire an ambulance to take me there. When I arrived, the nurses ignored me. In fact, they scolded me for getting pregnant at such a tender age. I was 16 at the time. While I was in labor, I passed out. I can’t recall what happened, but when I gained consciousness, I was in so much pain.

When my in-laws heard that I had delivered a stillborn baby, they called me a witch and returned me to my parents’ house. My problems started a few days later.

At first, I thought I just wasn’t making it to the toilet in time, but I was also wetting the bed at night. Now when I go to sleep I take a cloth and place it between my legs and put a plastic sheet underneath me so I won’t wet the bed. I can’t wear underwear because of the sores on my genitals.”

Nyaradzai’s story could be the story of many women living with fistula in Zimbabwe.

Fistula is a silent condition, and as a result many women are suffering in silence. Huge numbers of people are not aware of what it is or what it means for women.

A fistula is a passage or hole that has formed between two organs. Obstetric fistula is an abnormal opening that develops between the birth canal and the urinary tract. It is the primary type of fistula affecting women in developing countries.

Obstetric fistula is caused by lack of access to quality obstetric care, particularly prolonged and obstructed labour without treatment. Young girls can be at high risk, as their birth canals are still narrow. The head of the baby causes a tear between the birth canal and the bladder or rectum which, if not surgically repaired, leaves women incontinent.

2 million women in sub-Saharan Africa, Asia, the Arab region, and Latin America and the Caribbean are living with fistula. 

As Nyaradzai has experienced, the social isolation associated with physical symptoms can have significant mental health consequences. Obstetric fistula is almost entirely preventable, and its prevalence in the world is a sign that health systems are failing women.

I share Nyaradzai’s story today, on International Day to End Obstetric Fistula, to try to break the silence.  

It is important that we talk about fistula, teach communities about it and encourage women to help one another through education, empowerment and delaying marriage and child bearing.

Read more on girlsglobe.org and join the conversation online using #EndFistula.

The Impact of HIV on Adolescent Girls & Young Women

World AIDS Day celebrates its 30th anniversary this year with the theme of ‘Know Your Status’.

Great progress has been made since the first World AIDS Day in 1988 – 3 in 4 people living with HIV today know their status.

However, the work is not yet done – especially for women. Women account for more than half of the people living with HIV worldwide. In particular, adolescent girls (10-19 years) and young women (15-24 years) are significantly affected by HIV and have high prevalence rates.

In Eastern and Southern Africa, women make up 26% of new HIV infections despite making up only 10% of the population. Statistically, young women will acquire HIV five to seven years earlier than their male counterparts.

Why are women and girls at high risk of infection?

HIV disproportionately affects young women and girls because of their unequal social, cultural and economic status in society. These challenges include gender based violence, laws and policies that undermine women, and harmful cultural and traditional practices that reinforce stigma and the dynamic of male dominance.

Here some other reasons why gender inequality leaves women vulnerable to HIV:

  1. Lack of access to healthcare services – women encounter barriers to health services on individual, interpersonal, community and societal levels.
  2. Lack of access to education – studies show that educated girls and women are more likely to make safer decisions regarding sexual and reproductive health and have lower risk of partner violence.
  3. Poverty – an existing and overarching factor that increases the impact of HIV.
  4. Gender-based violence & intimate partner violence – these types of violence prevent young women from protecting themselves from HIV.
  5. ‘Blesser/Sugar Daddy’ culture and transactional sex – sex with older men for monetary or material benefits, exposes young women and girls to low condom use, unsafe sexual practices and increased rates of STIs.
  6. Child marriage – girls who marry as children are likely to be abused by their husbands and forced into sexual practices.
  7. Biological factors – adolescent girls are susceptible to higher rates of genital inflammation, which may increase the risk of HIV infection through vaginal intercourse.

Importance of HIV testing

HIV testing in young women and girls is essential. Many receive access to treatment and care services after testing. Some important determinants of testing are:

  • Going through antenatal care
  • Being married
  • Having primary and secondary education

We need to aim for more young women and girls to being tested so that they know their status, and can access adequate care and treatment services. HIV testing is necessary for expanding on treatment and ensuring that people with HIV have healthy, productive lives.

Addressing the Impact

To address the impact of HIV on young women and girls we need to have approaches and interventions that incorporate the diverse perspectives of women and girls. This is needed on all platforms from campaigning and policy-making to program design. As the World Health Organization recommends, a woman-centred approach that includes women as participants is required, so that our needs, rights and preferences are considered.

Better strategies are needed across all health system to improve accessibility, acceptability, affordability, uptake, equitable coverage, quality, effectiveness and efficiency of services, particularly for adolescent girls worldwide.

Family Planning Realities for Young People in Nepal

In many developing regions, young people still lack access to safe and effective family planning methods, for reasons ranging from lack of information or services to lack of support from their partners or communities. Young people are still being prevented from making informed autonomous decisions about their lives and their bodies.

Speaking from my own experience in Nepal, values about sexuality vary and are defined by culture and religion. One common barrier is social stigma, which discourages young people from openly discussing their needs and seeking the necessary interventions.

Nepal is one of the countries with fairly high adolescent fertility rates. Age at marriage is an especially important variable shaping fertility levels in Nepal, since it is a society where premarital sexual involvement is strongly disapproved of. The high rate of adolescent childbearing is a result of early age at marriage among women.

Nepal Demographic and Health Survey data reports some encouraging trends, such as the progressively increasing age at marriage over the past 15 years. However, there has not been a similar increase in the age at which adolescent girls begin childbearing.

In Nepal, the level of unmet need for family planning remains high.

Some adolescents cannot afford to pay for services, and even if they can, many fear that they’ll be required to provide parental consent before they can actually receive those services.

Young people have the right to make informed decisions about their lives. Integrating their perspectives and helping them overcome the social, legal and practical barriers they face is critical to achieving the goals of Family Planning 2020 (FP2020).

The Government of Nepal is committed to improving health outcomes in the country, and several policies and strategies have been put into place. The recent initiatives by government to provide family planning services through satellites and mobile clinics as well as community health volunteers is commendable to expand the reach of services in area of low accessibility.

Despite significant efforts, the idea of offering family planning services to young people is still not well accepted and easy to advocate for in Nepal. 

In advocating for young people’s rights to access family planning, factors such as age, religion, livelihood and education need to be taken into account. It is also true that young people are often more likely to seek information about reproductive health from informal sources.

Accordingly, to advance progress, information should be provided through media, peers and informal sectors. Peer education can be an effective in facilitating young people’s access to sexual and reproductive health (SRH) services and influencing social norms. Providing adolescents with Comprehensive Sexuality Education (CSE) has been shown to improve adolescent sexual reproductive health knowledge, attitudes, and behaviors when implemented well.

Adolescents and youth constitute a large section of the population in Nepal. Given its size and likely trajectory of growth in the future, this population warrants a focused policy attention, especially when it comes to education, health and population. Adolescents make up a high percentage of Nepal’s total population, and so policies and programs in family planning and reproductive health will have to be expanded to meet the needs of these groups.

For adolescent SRH programs to be effective, we need substantial efforts from the government along with the non-governmental organizations and the private sector. Unproductive approaches should be abandoned, proven approaches should be implemented. New approaches should be explored that better respond to adolescents’ needs.

We must commit to providing young people with the tools to take action in their communities and identifying funding opportunities for youth-led efforts.

As we continue to build the framework for Universal Health Coverage, we must ensure meaningful and sustainable youth engagement on family planning at all levels.

Women in Rural Zimbabwe are Being Left Behind

Being a young woman living in a rural or remote community can be very daunting. You have to fight tirelessly to loosen yourself from the grip of sociocultural stigmatization to have any sense of autonomy over your sexuality.

The situation is worsened by the absence of easy access to modern family planning methods. The problem lies in the fact that when coming up with sexual and reproductive interventions for women and adolescents, our governments still rely on ‘a one size fits all’ approach.

But women in rural areas have different lifestyles and challenges than women living in urban communities.

When it comes to sexual and reproductive health, one size fits all really makes no sense. One size fits all isn’t good enough.

In Zimbabwe, the fact that young women and adolescents in rural and remote communities are still struggling to access modern family planning methods – or even comprehensive sex education – is overlooked. These issues are still regarded as taboo, and in my community you can’t talk openly about them.

It’s a different scenario for women and adolescents in urban communities within Zimbabwe. In urban areas, it’s possible to access both information and services through youth friendly centres, Non Governmental Organisations and other diverse forums.

I believe that women can only enjoy their sexual and reproductive health and rights if they have access to relevant services and supplies – including access to contraceptives and accurate information on how to use them – regardless of geographical area or socioeconomic status.

The government of Zimbabwe is committed to ensuring improved availability of and access to quality integrated family planning services for all women irrespective of age, marital status and their geographical location by the year 2020.

A sizeable number of interventions have been made. For example, we now have an ambassador for Family Planning to advocate for family planning. This is a great initiative, but in rural areas this ambassador is not visible, and so issues are misrepresented! This type of intervention is relative – it primarily benefits the adolescents and young women in urban areas the brand ambassador is engaging with – which makes it an unfit approach for women collectively.

I believe that this kind of intervention leaves a lot of women behind. 

A large percentage of Zimbabwean women are in rural communities. Adolescents and young women in rural areas need interventions they can relate to – services that resonate with their particular reality and their existing level of understanding.

As much as there have been family planning and contraceptive outreach services, it is still absurd that in rural areas adolescents and young women continue to have unwanted pregnancies and new cases of HIV infections. The reason behind this is a lack of positive and affirmative approaches towards women’s sexuality.

From my experience in a rural area, the healthcare service providers are not youth friendly and they tend to have a negative perception of young women trying to access family planning. As a result, adolescents and young women shy away from these health centres as they don’t trust the service providers.

This is very disturbing, as trust should be one of the core values health service providers should strive to uphold at all times. I believe that it would be a great idea for genuinely youth friendly centres to be established in rural and remote areas. This would encourage adolescents and young women to seek out sexual education and feel comfortable asking questions about the family planning methods that will work best for them. It would also help conservative rural communities to recognize family planning as not only a priority, but also a right.

Sexual and reproductive health and rights of women and adolescents in rural communities should be prioritized in Zimbabwe, and the government must be held accountable for delivering meaningful and diverse approaches in tackling the family planning challenges our country faces. Without this, achieving the FP2020 targets will not be possible.

If truth be told, rural women and adolescents have had enough of being left behind.