A Mixed Methods Study of Multilevel Factors Influencing Sexual Risk-Taking Behaviors Among Adolescent Girls in Uganda

Background and purpose: Sub-Saharan Africa is home to two-thirds of people living with HIV globally. Adolescent girls and young women are twice as likely to be living with HIV compared to young men, including in Uganda. Adolescent girls experience multi-level risk factors that increase their vulnerability to HIV infection, including unequal cultural, social, and economic conditions. However, mixed methods studies examining multi-level and intersecting factors shaping adolescent girls’ decisions are limited. In this study, we qualitatively explored protective and risk factors that influence adolescent girls’ decision to engage in sexual risk-taking behaviors in Uganda and used social network analysis to complement the qualitative results.

Methods: As part of a 3-arm cluster randomized clinical trial that examined the impact of a combination intervention on reducing HIV risk among adolescent girls (n=1260) attending secondary school in Uganda, we qualitatively examined adolescent girls’ decision-making on sexual risk-taking. The inclusion criteria for the parent study were: 1) female; 2) aged 14–17 years; 3) enrolled in the first or second year of secondary school; and 4) living within a family. A stratified purposeful sampling (n=58) was utilized to select the qualitative sample. Semi-structured in-depth interviews were conducted following intervention completion. Informed by Eaton et al.’s framework, both inductive and deductive techniques were used for thematic analysis of the data. The factors identified in the qualitative data served as the unit of analysis for the social network of factors. A partial correlation matrix between the variables was generated to create the network. Descriptive statistics were used for network density and interconnectedness. Degree, closeness, and betweenness centrality were computed to identify the most influential variables.

Results: Protective and risk factors crossed across personal, proximal, and distal levels. At the personal level, only protective factors were mentioned and included future goals, concerns about negative health outcomes, “keeping busy”, and religion. At the proximal level, family relations, peer influence, and attitudes towards men were discussed both as protective and risk factors. At the distal level, poverty was mentioned as a risk factor and fear of being stigmatized as a protective factor. The network analysis showed the most prominent factors were future goals, health concerns, and family financial support, all of which were protective factors. The most prominent risk factor was poverty. The network analysis highlighted the relative strength and centrality of these factors within adolescents' social ecosystems. The prominence of 'future goals' as a central node provided quantitative justification for the motivational power of future aspirations detailed in the girls' narratives. The positioning of family relations and poverty within the social network echoed the qualitative insights regarding their dual roles as protective and risk factors.

Conclusions and implications: Study results suggest that given the complexity and multi-dimensionality of factors, combination interventions can provide the interdisciplinary multi-level response needed to reduce sexual risk-taking among adolescent girls in Uganda. These interventions should incorporate sexual health education, support for positive future orientation, strengthening family relations and communication around sex, and strategies to address poverty.