Sexual, Reproductive Health Needs, and Rights of Young People in Slum Areas of Kampala, Uganda: A Cross Sectional Study

Background Young people in Uganda face various sexual and reproductive health risks, especially those living in urban slums. The aim of this study was to examine factors associated with comprehensive categories of sexual and reproductive health, including sexual behaviours; sexual education and access to contraceptive services; family planning; prevention of STDs; sexual consent as a right; gender based violence; as well as HIV testing, counselling, disclosure and support. Methods The study was cross-sectional in design and was carried out in July 2014 in Makindye and Nakawa Divisions of Kampala City, Uganda. Using systematic random sampling, data were collected on 663 participants aged between 13 and 24 years in Kampala’s urban slums. Results Sixty two percent of participants reported having ever had sex and the mean age of sexual debut was 16 years (95%CI: 15.6, 16.4 years, range: 5–23 years). The odds of reporting ever having had sexual intercourse were higher among respondents living alone (OR: 2.75; 95%CI: 1.35, 5.61; p<0.01) than those living in a nuclear family. However, condom use was only 54%. The number of sexual partners in the last 12 months preceding the survey averaged 1.8 partners (95%CI: 1.7, 1.9; range 1–4) with 18.1% reporting an age gap of 10 years or older. More than three quarters (80.6%) of sexually active participants reported that their first sexual encounter was consensual, suggesting that most young people are choosing when they make their sexual debut. Low prevalence of willing first sexual intercourse was associated with younger age (OR = 0.48, 95%CI: 0.25, 0.90, p<0.05), having a disability (OR = 0.40, 95%CI: 0.16, 0.98, p<0.05), living with non-relatives (OR = 0.44, 95%CI: 0.16, 0.97, p<0.05), and being still at school (OR = 0.29, 95%CI: 0.12, 0.67, p<0.01). These results remained significant after adjusting for covariates, except for disability and the age of participants. The proportion of unwilling first sexual intercourse was significantly higher among women for persuasion (13.2% vs. 2.4%, p<0.001), being tricked (7.1% vs 2.9%, p<0.05) and being forced or raped (9.9% vs 4.4%, p<0.05) than men. A high level of sexual abuse emerged from the data with 34.3% affirming that it was alright for a boy to force a girl to have sex if he had feelings for her; 73.3% affirming that it was common for strangers and relatives to force young females to have sexual intercourse with them without consent; 26.3% indicating that it was sometimes justifiable for a boy to hit his girlfriend, as long as they loved each other. Conclusion This study has explored current sexual practice among young people in a specific part of urban Kampala. Young people’s sexual and reproductive health remains a challenge in Uganda. To address these barriers, a comprehensive and harmonised sexual and reproductive health system that is youth friendly and takes into account local socio-cultural contexts is urgently needed.


Methods
The study was cross-sectional in design and was carried out in July 2014 in Makindye and Nakawa Divisions of Kampala City, Uganda. Using systematic random sampling, data were collected on 663 participants aged between 13 and 24 years in Kampala's urban slums.

Results
Sixty two percent of participants reported having ever had sex and the mean age of sexual debut was 16 years (95%CI: 15.6, 16.4 years, range: 5-23 years). The odds of reporting ever having had sexual intercourse were higher among respondents living alone (OR: 2.75; 95%CI: 1.35, 5.61; p<0.01) than those living in a nuclear family. However, condom use was only 54%. The number of sexual partners in the last 12 months preceding the survey averaged 1.8 partners (95%CI: 1.7, 1.9; range 1-4) with 18.1% reporting an age gap of 10 years or older. More than three quarters (80.6%) of sexually active participants reported that their first sexual encounter was consensual, suggesting that most young people are choosing when they make their sexual debut. Low prevalence of willing first sexual intercourse was associated with younger age (OR = 0.48, 95%CI: 0.25, 0.90, p<0.05), having a disability (OR = 0.40, 95%CI: 0.16, 0.98, p<0.05), living with non-relatives (OR = 0.44, 95%CI: 0.16, 0.97, p<0.05), and being still at school (OR = 0.29, 95%CI: 0.12, 0.67, p<0.01). These results remained significant after adjusting for covariates, except for disability and the age of a1111111111 a1111111111 a1111111111 a1111111111 a1111111111

Introduction
Sexual and reproductive health and rights (SRHR) broadly applies the concept of human rights to sexuality and reproduction, and is concerned with the intersection of four distinct fieldssexual health, sexual rights, reproductive health, and reproductive rights-of sexual and reproductive wellbeing [1,2]. To maintain one's sexual and reproductive health, access to accurate information (e.g. seek, receive, and impart information related to sexuality) and a choice of safe, effective, affordable contraception options are key [2,3]. A human rights framework emphasizes access to information to empower individual freedom of choice with respect to: deciding whether to be sexually active or not (e.g. sexual debut); the pursuit of a satisfying, safe, and pleasurable sexual life; choosing a partner; consensual sexual relations and consensual marriage; protection from sexually transmitted infections (STIs); and family planning (e.g. whether or not, and when, to have children) [2]. The availability of, and access to, health and information services for women and girls that facilitate healthy pregnancies, births, mothers and babies is also essential to good sexual and reproductive health [4].
Young people in sub-Saharan Africa face various sexual and reproductive health risks such as unplanned pregnancy and sexually-transmitted infections (STIs), including HIV [5,6]. Sub-Saharan Africa has a high level of HIV, with the 2015 Global Health Observatory data suggesting that the region remains most severely affected, and has the highest adult HIV prevalence [7]. Compared with an average HIV prevalence of 0.8% among adults aged 15-49 years worldwide, nearly one in every 25 sub-Saharan African adults (4.4%) live with HIV, and the region accounts for nearly 70% of the people living with HIV worldwide [7]. With an HIV prevalence of 4.4%, sub-Saharan Africa compares unfavourably with South East Asia (0.3%), the Americas (0.5%), Europe (0.4%), East Mediterranean (0.1%) and the Western Pacific (0.1%) [7]. Similarly, other studies in sub-Saharan Africa have shown a high prevalence of syphilis, gonorrhoea, bacterial vaginosis, trichomoniasis and herpes simplex virus type 2 [8,9].
In the last decades of the 20 th century Uganda achieved tremendous progress in fighting the HIV/AIDS pandemic, and reduced the prevalence of the disease in the general population from 15% in the early 1990s to 7.0% in 2014 [10]. However, HIV/AIDS in Uganda is unequally distributed and some sections of the population are more affected than others, with the prevalence higher in urban areas than rural areas (8.7% vs. 7%), higher in women than men (8.3% vs. 6.1%), and two-to-three times higher among fishing communities (22%), commercial sex workers (35%) and men who have sex with men (13%) [10]. Among young people aged 15-24 years, the prevalence of HIV/AIDS is significantly higher among young women (4.2%) than young men (2.4%) [10]. In addition, overall around one in three young people have comprehensive and correct knowledge of HIV/AIDS [10]. Furthermore, Uganda retains a high burden of other sexual and reproductive health risks such as teenage pregnancy, with 33% of Ugandan women having given birth before the age of 18 years which is among the highest in the world [11]. The high pregnancy rate among adolescents is compounded by the unmet contraceptive needs of almost half of the fertile and sexually active women [12].
Whilst Uganda has a national adolescent health policy that aims to streamline adolescent health concerns into the national development process to improve young people's quality of life and standard of living [13], its impact on the sexual and reproductive health needs of young people has been less than adequate. For example, previous studies [14][15][16] have identified young people in Uganda and other sub-Saharan African countries as having limited access to contraception, and a lack of staff trained to address the sexual health needs and education gaps of young people. Key issues that have negatively impacted upon young people's sexual and reproductive health include unwanted pregnancies, sexually transmitted infections (STIs), defilement, rape, and substance abuse [14]. Access to legal abortion also poses a challenge as it is legally restricted [17][18][19][20].
Whilst it has been well documented that recognising adolescents and young people as a priority is one of the prerequisites to achieving bold international goals such as the millennium and sustainable development goals [21,22], adolescent health, especially sexual and reproductive health, remains a challenge and is poorly addressed by these international development agendas [23]. Suboptimal sexual and reproductive health not only increases morbidity, mortality, and gender inequity, it also slows development [14,24]. Addressing adolescent sexual and reproductive health needs in Uganda is especially important, as a growing number of young people are sexually active [14]. There is a strong link between sexual abuse and the risk of unintended pregnancy [25]. Coerced sexual debut has been found to be associated with increased risk of ongoing coercion, which has adverse reproductive health outcomes including: decreased contraceptive use; non-use and inconsistent use of condoms; unintended pregnancy; and genital tract symptoms, possibly indicating the presence of an STI [25]. Early marriage and early sexual activity often drive a high incidence of complications from pregnancy and delivery. In addition, sexual advances by older men and practices of transactional sex make adolescent females particularly vulnerable to sexual, reproductive and health risks [26].
In Uganda, there is a discrepancy between universally formulated sexual and reproductive health rights and the local political, economic and community contexts in which young people live [27]. This discrepancy requires that a comprehensive rights-based sex education takes this local reality into consideration [27], however, most of the studies on sexual and reproductive health rights summarised above focused on the limited dimensions of sexual health rights (SHR). Specifically they are narrow in scope and are not comprehensive in the analysis of the local socio-cultural contexts that shape the sexual and reproductive health needs and rights of young people in Uganda. To comprehensively explore the socio-cultural contexts that influence sexual and reproductive health needs and rights of young people in Uganda, the application of a societal theory is indispensable. The socio-ecological theory was adopted in this study to explore the interdependent complex relationships that exist between individual (i.e. skills, knowledge, attitudes, beliefs and behaviours), interpersonal (i.e. social networks and social support systems that influence individual behaviours, including family, friends, and customs or traditions), community (i.e. established norms and values including rigid gender roles, peer pressure, loss of traditional support, and economic hardships), organizational (i.e. rules and practices such as disapproval from health workers, geographical accessibility, inadequate counselling from health workers or lack of privacy), and environment (i.e. policies on sexual and reproductive health, HIV, and AIDS including HIV/AIDS counselling), factors [28,29].
In addition, while HIV prevalence is typically higher in urban than in rural settings in sub-Saharan Africa there are strong intra-urban differences in the risk of HIV infections. While a growing body of research has focused on poor health outcomes among the urban poor, HIV and its risk factors have attracted little attention. The low employment opportunities outside the capital means that Kampala attracts a large numbers of young people in search of work. Within Kampala, the two divisions of Nakawa and Makindye is where the research project was carried out. Over the past two decades these two divisions have been characterised by high unemployment in concert with a high dependence burden and rampant crime, which presents strong barriers to youth participation in community programmes and negatively affects their well-being [30]. Despite the dire economic and social situations that predispose youth to HIV, studies into their sexual behaviours, sexual education and access to contraceptive services, family planning, sexual consent as a right, and gender based violence are lacking. The few available data emerging from Kenya suggest that residents of urban slum areas have a higher HIV prevalence than urban non-slum residents and engage in riskier sexual practices than other sub-groups [31]. Therefore, the aim of this study was to examine factors associated with comprehensive categories of sexual and reproductive health among young people in slum areas of Kampala, Uganda, including: sexual behaviours; sexual education and access to contraceptive services; family planning; prevention of STDs; sexual consent as a right; gender based violence; as well as HIV testing, counselling, disclosure and support.

Study design and sampling strategies
The study was cross-sectional in design and was carried out in July 2014 in Makindye and Nakawa divisions of Kampala City, Uganda. The study focused on youth (13-17 years) and young adults (18-24 years). Uganda has one of the youngest and fastest growing populations in Africa, with a 2013 estimate placing it at 35.5 million. More than three quarters (78%) are aged below 30 years [32]. Ugandan youth make up the largest proportion of the population, but they are negatively affected by youth unemployment rates of 61.6%, among the highest in Africa [33,34]. The absence of employment opportunities outside of the capital Kampala has led to significant numbers of young people entering the city in search of work.
The Kampala City Council is composed of divisions, and each administrative division is comprised of parishes, divided into zones. A total of 391 zones were identified in the two target divisions. A list of all zones within the parishes of the Makindye and Nakawa divisions was established for sampling purposes. A list of households in each of the zones was constructed with the help of the local councils, and from the list, a household was selected using a systematic sampling approach. Households in each zone were given a unique identification number. Given that zones varied in size, the number of households to be surveyed in each zone was proportional to the size of the zone. The sampling interval (X) was determined by dividing the total number of households in each zone with the expected sample size, and the first household to be surveyed was randomly selected by choosing a number between 1 and X. The next household to be visited was selected by adding X to the first randomly selected number, and the process continued until the required sample size for that zone was obtained. For each selected household, a person aged 13-24 years volunteered to take part in the study and the interview occurred outside the home, away from other household members. If the selected household was not inhabited, or there was no one at home, the closest neighbouring household was used for the survey. In the case of a household having more than one eligible participant, the interviewer randomly selected one participant to be included in the study. The study was approved by the Monash University Human Research Ethics Committee (approval no. CF16/1001-2016000532).

Procedure and data collection
Studies in sub-Saharan Africa have shown that low community awareness about health research and the participants' perception that signing consent forms is not a good approach due to the potential legal accountability decrease research acceptance and participation rates [35]. Therefore, trained data enumerators, who were bilingual (English and Luganda) explained the study to participants in either English or Luganda through a plain language statement. Written and verbal consent (witnessed) was sought from participants. For children aged 13-17 years we did not seek parental permission for two reasons: 1) children were able to understand or appreciate what the research entailed given their exposure to multi-media HIV campaigns at all levels of community structures [36], and 2) discussing sexual matters was a sensitive issue and seeking parental consent would have been inappropriate and may have prevented young people discussing freely their sexual health needs and rights [37]. Where participants were able to provide a signature, signed informed consent was secured. For those who could not sign due to cultural and political reasons, the consent was oral. Since data collectors worked in pairs due to security reasons, the oral consent was recorded by the primary data interviewer on behalf of the participant and witnessed by the assisting data collector [38].
A total of 834 households were contacted, of which 158 did not participate due to family commitments; a further 13 interviews from 13 households were incomplete and were excluded from the analysis, giving a total sample size of 663 interviews with valid data and a response rate of 79.5%. Data were collected by 12 trained enumerators, who were supervised by four experienced field coordinators to monitor quality control. Data enumerators, who were bilingual (English and Luganda) were trained over three days, followed by a field testing of the questionnaire prior to data collection to ascertain its cultural appropriateness. The training covered sampling techniques, interview techniques and ethical issues including confidentiality and respect (i.e. the right of a participant to refuse to respond to a question or to the entire survey), and participants' familiarisation with the questionnaire. Bilingual workers administered the survey in English. The research implementation was overseen by a steering committee comprised of staff from World Vision, four field coordinators, and representatives from youth organisations. The steering committee approved all processes and commented on the questionnaire.

Survey instruments
A structured questionnaire was used to collect data at the household level. It had four sections: demographics of household members (age, gender, ethnic group, educational attainment and religion), sexual behaviours, sexual and reproductive health rights, and sexual and reproductive health needs. The questionnaire was field tested prior to data collection for cultural appropriateness and clarity and was administered in English by trained bilingual workers, translating into Luganda when appropriate. independent variable) was initially examined using the chi-square test. Adjusted logistic regression analyses were performed to determine the best prediction of a dependent variable from several demographic and socioeconomic variables. For all the categorical variables, the lowest coded category was the reference. The level of statistical significance was set at a probability of P < 0.05 for all tests. The univariate analyses were screened to identify variables to be included in the multiple linear analyses, and all variables whose p-value approached significance at 10% underwent multiple regression analyses [39,40]. However, the level of statistical significance for establishing an association was set at a probability of P < 0.05 for all tests.

Participant demographics
The characteristics of the study's participants are summarised in Table 1. A total of 663 youth and young adults participated in our study, of whom 650 provided data on their gender (44.9% were female). One in three (33.2%) surveyed young people were aged 13-17 years, while 66.2% were aged 18-24 years, with the average age of the study sample being 19.5 (95% CI: 19.3, 19.8) years. The mean age of educational attainment was 9.2 (95%CI: 8.9, 9.5) years, that is, lower secondary level, with 39.6%, 31.4%, 15.3% and 13.7% completing seven years or less (primary or less), 8-11 years (lower secondary), 12-13 years (upper secondary) and 14 years or more (post-secondary) of schooling respectively. Only a quarter of the surveyed participants (24.9%) lived in a nuclear family (i.e. with father and mother) while 24.6% lived in a single parent-headed family, 23% lived alone, 20.5% lived with relatives, and 7.1% lived with non-relatives. The proportion of youth and young adults identifying themselves as having disability was 7.5%.

Sexual behaviours and source of information about sexual education
The study found that the majority of participants in the study area were sexually active, with 405 of the 647 respondents (62.6%; 95%CI: 58.8%, 66.3%) reporting having ever had sex. Bivariate analyses found that the proportion of participants who have ever had sex did not vary by gender, but significantly differed according to whether or not the participant had a disability, living arrangements, educational attainment, and employment status (Table 1). These results remain consistent after adjusting for socio-demographic and economic factors. In the adjusted model (data not shown) containing gender, age, whether or not the participant had a disability, educational attainment, living arrangements, and employment status (Pseudo R 2 = 0.300), the odds of reporting ever having had sexual intercourse were lower among 13-17 year old participants (OR: 0.22; 95%CI: 0.13, 0.37, p<0.001), participants who never went beyond primary school level (OR: 0.39, 95%CI: 0.18, 0.85; p<0.05), and participants still at school (OR: 0.27, 95%CI: 0.14, 0.50; p<0.001) when compared with participants aged 18-24 years, with postsecondary education, and with full time paid employment respectively. However, the odds of reporting ever having had sexual intercourse were higher among children and young adults living alone (OR: 2.75; 95%CI: 1.35, 5.61; p<0.01) than those living in a nuclear family. The effect of disability became non-significant.
The intercourse was associated with a low level of educational attainment and living with relatives, before and after adjusting for covariates. While the proportion of boys reporting using condoms the last time they had sexual intercourse was higher than that of girls (58.4% vs. 48.4%, p<0.05), this difference disappeared in the adjusted model. Of those who reported being sexually active, 390 out of 405 (92.3%; 95%CI: 89.2, 94.5) reported having had sexual intercourse in the last 12 months preceding the survey, and the prevalence was significantly lower among boys than girls (87.6% vs. 97.3%, p<0.001), and among those still at school when compared to those in the workforce (82.7% vs. 94.0% p<0.05). Adjusting for covariates did not make any difference.
In the 12 months preceding the survey sexually active youth and young adults reported an average of 1.8 partners (95%CI: 1.7, 1.9; range 1-4) but the average number of sexual partners was significantly lower for females than for males (1.6 vs.1.9; p<0.05). Of the 390 participants who were sexually active in the 12 months preceding the survey, more than half (58.9%) had one sexual partner, while 19.2% had two sexual partners, 8.9% had three sexual partners, and 13% had four sexual partners. Among males, the number of sexual partners was closely associated with employment status, with low number of sexual partners associated with being unemployed.
While 28.9% of respondents did not know if their most recent sexual partner was much older or younger, 18.1% reported an age gap of 10 years or older, 4.5% reported 6-9 years, 35.2% reported 2-5 years and 13.4% reported one year or less.

Sexual consent as a right and gender-based violence
Data on sexual consent as a right and gender-based violence are summarised in Tables 2, 3 and 4. More than three quarters (80.6%) of the participants who reported ever having sexual intercourse had willing (i.e. consensual) first sexual intercourse, although this proportion was significantly lower among girls than boys (69.8% vs. 90.2%, p<0.001). Low prevalence of willing first sexual intercourse was associated with younger age (OR = 0.48, 95%CI: 0.25, 0.90, p<0.05), having a disability (OR = 0.40, 95%CI: 0.16, 0.98, p<0.05), living with non-relatives (OR = 0.44, 95%CI: 0.16, 0.97, p<0.05), and being still at school (OR = 0.29, 95%CI: 0.12, 0.67, p<0.01). These results remained significant after adjusting for covariates, except for disability and the age of participants. Significant proportions of participants reported being persuaded to have sex through gifts, money or other favours (7.4%) (95%CI: 5.2, 10.5); tricked or deceived (5%) (95% CI: 3.3, 7.8); while 6.8% (95%CI: 4.8, 9.9) were forced to have sex and raped during their first sexual intercourse. The proportion of unwilling first sexual intercourse varied significantly by gender, with the proportion of sexually active women reporting being persuaded (13.2% vs. 2.4%, p<0.001), tricked (7.1% vs 2.9%, p<0.05) and forced or raped (9.9% vs 4.4%, p<0.05) at first sexual intercourse being significantly higher than that reported by sexually active men. However, apart from persuasion, these results became non-significant after adjusting for covariates.
One in 13 participants (7.4%) indicated that, if someone tried to have sexual intercourse with them or touch them sexually without their consent, they would definitely not be able to prevent it happening, and this was more significantly so among 13-17 year old participants than their older counterparts (11.1% vs 5.8%, p<0.01). Although 77.2% of young people indicated that a girl can confidently suggest to her boyfriend to use a condom without fear or hesitation, some 48.5% of respondents indicated that a boy will not respect a girl who agrees to have sex with him if she insists on him using a condom. One third of participants (34.3%) affirmed that it was alright for a boy to force a girl to have sex if he had feelings for her, even if she didn't have the same feelings for him, while three quarters of respondents (73.3%) also believed it was common for strangers and relatives to force young females to have sexual intercourse with them without consent. Some 26.3% of participants indicated that it was sometimes justifiable for a boy to hit his girlfriend, as long as they loved each other. These held beliefs and attitudes did not vary by gender or age, hence highlighting the tolerance and endorsement of culturally-mediated gender-based sexual violence. Approximately half (52.0%) of the study's Table 4

. Association between sexual and reproduction health needs and rights and demographic and socio-economic characteristics.
All Female Male Pvalue

Sexual and reproduction health right and needs
If someone tried to have sexual intercourse with you or touch you sexually and you did not want them to, would you be able to safely stop them? % answering "definitely not" N (%) 49  Sexual, Reproductive Health Needs, and Rights of Young People in Uganda participants affirmed that they would never contemplate having an abortion if a sexual partner (not married) became accidently pregnant; while 62.8% (female: 67.8% vs male: 58.7%, p<0.05) agreed that it was mainly the woman's responsibility to ensure that contraception was used regularly to prevent unwanted pregnancy and/or diseases.
Access to contraceptive services, family planning, and prevention of STDs Data on access to contraceptive services, family planning, and prevention of STDs are summarised in Table 5 and Fig 1. The majority of participants (76.6%) knew where and how to access condoms, pills, intrauterine devices, or birth control implants for planning birth control purposes, but the proportion was significantly lower among 13-17 year old participants than their older counterparts (62.8% vs 80.8%, p<0.001). Just half (48.6%) of participants had visited a health facility to get information on family planning and STDs in the last 12 months preceding the survey, with younger participants less likely than their older counterparts to visit a health facility (37.3% vs 52.8%, p<0.01). Two in three (66.6%) study participants knew of somewhere (or someone) nearby where they could go to get help if they needed information concerning abortion, or to obtain an abortion. More than three quarters (79.5%) affirmed that they could make decisions about whether or not, and when, to have children without fear. Data in Fig 1 indicates that female condoms, post-exposure prophylaxis, abortion services and counselling were not readily available and accessible. In addition, those services that were highly available were not necessarily affordable, especially post-exposure prophylaxis, STIs testing and counselling, HIV treatment, birth control pills and implants, pre-, peri-, and post-natal health care, and pregnancy testing.
HIV testing counselling, disclosure and support Data on HIV testing counselling, disclosure and support are summarised in Table 6. The majority of the study participants (80.5%) affirmed that they would be given pre-and post-testing counselling if they were to undertake an HIV test, and 73.8% affirmed that they would be able to safely disclose the result of their HIV test to their partner without fear, either if the partner was present at the time of the test, or if the partner was not with them at the test but was informed later. Three quarters of participants (75.1%) indicated that there were HIV treatment, care and support services in their community to serve those who become HIV+.
When asked which issues they would prioritize if given an opportunity to attend a meeting, HIV prevention topped the list, ahead of sexual and reproductive health needs, and followed by stopping gender-based violence, gender equality, and sexual and reproductive rights ( Table 7). Three quarters (76.3%) of interviewed young people indicated knowing their health responsibilities, especially the responsibility to seek medical care, to follow treatment instructions, and to provide information. However, young people's knowledge of Ugandan health policies was very poor.

Discussion
The study was the first effort to assess the sexual health needs and rights of young people in slum areas of Kampala using a large sample size. The use of a systematic random sampling method provided the opportunity to obtain a sample that is highly representative of the target population. The large sample size and the use of systemic random sampling make conclusions from our data valid. However, the study's sample is limited to young people in slum areas of Kampala and our findings cannot be generalised among young people in Uganda. Our study was cross-sectional, hence limited to investigating the association between the independent and dependent variables, controlling for confounding factors. Causation cannot therefore be implied. Some of the data on sexual health needs and rights were collected retrospectively, Table 5. Association between access to contraceptive services and family planning, prevention of STDs, and demographic and socio-economic characteristics.

Characteristic
It is mainly the woman's responsibility to ensure that contraception is used regularly to prevent unwanted pregnancy and/or diseases hence it is possible that our data may have been subject to the recall bias. Notwithstanding these limitations, findings from this study have a wide range of policy implications.
Our study findings show that almost 81% of young people aged 18-24 years and 27% aged 13-17 years were sexually active. However, in both age groups condom use was only 54%. The strongest variable of condom use in sexual intercourse was its use in the last sexual encounter preceding the study. This is important because consistent and correct condom use prevents sexually transmitted diseases and early and unwanted pregnancies. Similar findings have been reported in youth studies, implying that sexually active youths who consistently use condoms protect themselves from sexually transmitted diseases and unwanted pregnancies [41][42][43].
Our data suggests that almost 77% of the sexually active respondents in upper secondary schools used condoms compared to 50% and 39% in lower secondary and primary schools. This implies that young people in upper secondary school gain critical knowledge which influences their sexual decisions. This is consistent with studies that found that sexuality education among the youth reduces risky behaviour, unwanted pregnancy and sexually transmitted diseases [44,45]. However, it is possible that sexually active young people in lower secondary and primary schools have limited access to sex education and negotiation power over condom use, especially if their sexual partners are older. Lack of in-depth sex education and negotiation skills in lower secondary and primary schools exposes younger age groups at risk. Evidence suggests that sex education is most effective when delivered to pre-sexually active young people [46,47]. This could explain why condom use among post-secondary youths was 12% lower than in respondents with higher secondary education given that sexual debut occurs at very young age.
Living arrangements were strongly associated with condom use during sexual intercourse. Sexually active participants who lived with either one or two parents, and those who lived alone, were more likely to use a condom during sexual intercourse, compared with those who lived with other relatives. This suggests that young people living with relatives other than their parents, and those living with no relatives, were more vulnerable to sexually transmitted diseases and unwanted pregnancy because of limited negotiation powers with their sexual partners concerning condom use. Similar findings have been reported in youth studies elsewhere implying that young people living away from their parents are at a greater risk of sexual exploitation and abuse [48,49]. Our findings suggest that young people knew how and where to access other forms of contraception apart from condoms. This finding may be due to the health policy environment of Uganda, which emphasizes effective control of STIs, and preventing unwanted pregnancies and their consequences. This policy direction is likely related to Uganda's much acclaimed success in reducing the prevalence of HIV between the 1990s and mid 2015 from 15% to 4.4%, which was itself premised on strong behaviour change campaigns [50,51]. However female condoms, post-exposure prophylaxis, and abortion services were inaccessible and unaffordable. Unaffordability of contraception services is a likely correlate of Uganda's 31-40% rate of unwanted pregnancies, which is one of the highest in the world [52,53]. Unaffordable contraceptive services could be one of the distal determinants of the common occurrence of child  abandonment in Kampala [54]. Evidence suggests that teenage school girls who fall pregnant drop out of school [55,56], a double tragedy that further entrenches them and their offspring into a cycle of poverty due to missed education opportunities. Uganda could benefit from liberal and open access contraception policies to reduce teen pregnancies, adolescent births and child abandonment. Uganda could learn from the policies of countries like Switzerland and Slovenia, where young people have access to a wide range of contraception services, and record very low rates of teen pregnancy, 0.9% and 0.12% respectively [57]. Not surprisingly, 80.6% of the study participants reported their first sexual encounter was consensual, suggesting that most young people are choosing when they make their sexual debut. Therefore, the onus is on parents, guardians and policy makers to accept adolescent sexuality as a fact, and to provide adolescents with comprehensive sex education. Without this realisation, the social expectation that teens are not sexually active-or that those who are will consistently use contraception-remains a fallacy. Notwithstanding the consensual sexual debut, our data suggests a significant rate of non-consensual sexual debut among the vulnerable younger age group, those with a disability, young people living with non-relatives, and those still at school. Sexual debut as early as nine years suggests a highly sexualized environment in which children engage in sex at an early age, often without their consent. Very young children, especially girls, are exposed to risks such as STIs, early pregnancies and obstetric fistula when they attempt to give birth before their bodies mature [58]. Reports suggest that some sex offenders who are wealthy or have 'connections' remain unpunished and are in positions where they continue to abuse their victims without repercussions [59]. Furthermore, we noted that 7.4% of the respondents indicated powerlessness to prevent sexual abuse against them. Stronger action-backed policies are required to protect vulnerable young children, the disabled, and those living away from their parents, from sexual abuse. There is an urgent need for accelerated empowerment of young people with skills and information on prevention and avoidance of unwanted sexual attention, and strategies for how to identify potential sexual abusers.
Uganda successfully rolled back HIV infections especially during the 1990s and early 2000s [60]. Evidence suggests that the decline in multi-partner sexual behaviour was one of the correlates of the decline in HIV infections [51,61]. However our data suggests that more than half of the study respondents had sexual relationships with multiple partners in the past 12 months, a trend that would seem to undermine the government's efforts in preventing HIV transmissions. Nonetheless, our findings present an opportunity for new and creative prevention approaches that specifically target young urban people in low resource settings. Uganda has one of the youngest and most youthful populations with 31.4% of the 34.9 million Ugandans aged between 10-24 years [62]. Therefore, specific HIV prevention initiatives targeting young people in slum areas are a direct investment in a productive and future AIDS-free workforce.

Conclusion
This study has explored current sexual practice among young people in a specific part of urban Kampala. Young people's sexual and reproductive health remains a challenge in Uganda with significant barriers such as inaccessible and unaffordable services. To address these barriers, a comprehensive and harmonised sexual and reproductive health system that is easily accessible, youth friendly and affordable, and which takes into account local socio-cultural contexts is urgently needed. Such a system needs to incorporate robust sexuality education in lower primary schools, where the majority of children are enrolled due to free universal primary education. Additionally, a functional sexual and reproductive health system with adequate resourcing would be of benefit to all Ugandans. Supporting Information S1 Appendix. Supporting Information. Baseline questionnaire -Sexual, reproductive health needs, and rights of young people in slum areas of Kampala, Uganda. (DOC)