Summary of paper

HIV and AIDS continues to be an ongoing concern in many countries globally and even more so for African countries. Research published in 2012 by Stephen A. Bell, “Young people and sexual agency in rural Uganda” examines the decision making process leading young Ugandans involvement in sexual relationships, the transactional negotiations and factors that may influence sexual health decision making choices.1

Bells’ research builds on existing literature as it examines how young people’s sexual agency has an impact on their sexual health choices and lifestyles; with the intention of providing health promotion practitioners a more sensible and practical starting point from which to design HIV and sexual health programmes. Bell contextualises his research with a broader framework of “empowerment”. The research seeks to explain how young people (11 – 24 years old) make choices regarding their sexual behaviour unpacking the type of information available to them, contraceptive knowledge and the stigma attached to sexual activity at an early age.1

Bell’s research inquiry is informed by the theoretical framework of “individual agency, defined by Petesch, Smulovitz and Walton as the capacity of individuals to make purposeful choices and transform these into desired actions and outcomes”.2 In doing so, Bell discusses the notion of “sexual agency” to refer to a process where young people become sexually active and the strategies, actions and negotiations involved in navigating broader social expectations.

The study design incorporates multiple qualitative methods. The research is conducted in three rural locations in Uganda over 2 years. The methods applied are focus groups and structured interviews. The focus groups sample is drawn from local schools and non-school attendees. From the focus groups purposive sampling is used to then invite participants to participate in the structured interviews. A broad range of topics are discussed including what they liked or disliked about their communities, their social and cultural expectations, home situations, their social networks, economic and social wellbeing, relationships and sex and their aspirations for the future.

The 3 key findings reported were:

1. Factors influencing decision making leading to involvement in sexual and intimate relationships;
2. Actions and negotiations within these relationships; and
3. Outcomes arising from sexual agency. 1

Critique

The research provides a detailed and rich insight to the decision making process of young people regarding sexual health. In light of this, a more detailed examination that focuses on the generalizability of the findings to a different and diverse population is required.

Focus groups (between 8 and 12 participants) are social contexts characterised by the forms of communicative interaction and meaning making found in everyday conversations. 3 The purpose of the focus group is to draw upon the participants’ attitudes, beliefs, feelings experiences and reactions in way not possible using other methods. These attitudes, feelings and beliefs are more likely to be revealed via a social gathering and the interaction which being in a focus group entails.4

Focus groups are flexible in nature, have high face validity and can generate lots of data however there are also limitations to this approach namely, in recording, transcribing and analysing this data which needs to be taken into account. In the case of Bells research the chance of introducing error or bias are particularly high if the discussion has to be translated from the native language to the language of the investigator and this a problem which is significant in multilingual environments. Bells linguistic attributes in the local language is not disclosed nor the language used in the focus group session. Considering the age of some of the participants and the potential cultural influences, free expression is not always possible in a group setting and the group can in fact inhibit discussion. For example, Vlassoff (1987) described a focus-group discussion amongst adolescent girls in India, during which the girls were painfully shy, not wishing to discuss their opinions in front of other people, despite extensive efforts to create a relaxed setting conducive to discussion.5

Other limitations of focus groups are their small samples size as well as being purposively selected. The results from this sample may not allow generalization to larger populations where the research outcomes may be applicable. In addition, as with other qualitative methods, the chances of introducing bias and subjectivity into the interpretation of the data are high.6 While the focus-group discussion can provide plausible insights and explanations, one should not extrapolate from focus group discussions to a broader and heterogeneous population. This tenet may not always be followed. In fact Merton, a key author of focus-group discussions, suggests that “focus group research is being mercilessly misused as quick-and-easy claims for the validity of the research are not subjected to further, quantitative test”.7

Implications of Position

Due to the abovementioned limitations the data gathered may not provide a conclusive guide across other young people populations in similar settings, i.e. Ugandan communities or other countries in the region. This in turn makes it difficult for health promotions agencies to develop and deliver programmes focus on “safe sexual health” practices targeting the young people aged between 11 and 24 years. The Ottawa Charter for Health Promotion (WHO, 1986) emphases the need to create supportive environments and strengthen community actions.8 What is evident is the need to educate the whole community to facilitate social change. There are multiple theories underpinning community wide approaches to health promotion for example, the three-stage Freirian Praxis Model of change suggests that people engaged in Freirian programs can evolve beyond powerlessness to create a sense of empowerment—that they can make a difference in their worlds.9

Bell reports that young people do know what they are doing in relation to their sexual choices; they are able to articulate their needs and feelings and then act on these. The research provides valuable insight and health promotion programme designers may want to consider how these can be tailored and incorporated to a local context. Further research is required to understand the community at large and the cultural influences that may be barrier to young people accessing timely, accurate and appropriate sexual health information.

References:

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