1. CyberSenga Dissemination
Meeting
SESSION 2:
DEVELOPING CYBERSENGA:
DATA INFORMINGTHE CONTENT
*Thank you for your interest in this presentation. Please note that analyses
included herein are preliminary. More recent, finalized analyses may be available
by contacting CiPHR for further information.
MicheleYbarra MPH PhD
Center for Innovative Public Health Research
Julius Kiwanuka MD
Mbarara University of Science & Technology
Conducted at the Acacia Hotel, Mbarara, Uganda, May 29, 2012

2. UNDERSTANDINGWHY AND HOWYOUTH
MAKE SEXUAL DECISIONS:FINDINGS FROM
INTERVIEWSWITH ADOLESCENTS AND
ADULTSWORKINGWITHYOUTH A
DEVELOPING CYBERSENGA:
DATA INFORMINGTHE CONTENT
A Excerpts from: Katz IT,Ybarra ML,Wyatt M, Bangsberg
D, Kiwanuka J,Ware N. Sociocultural and Economic Antecedents of
Adolescent Sexual Decision Making in Rural Uganda. Under review.

3. Methods
 In 2008, we talked to:
◦ 48 adolescents (24 boys and 24 girls) and
◦ 15 adults (9 women and 6 men) who work
with adolescents
 The aim was to understand young
people‟s information about HIV, the
reasons why young people choose to play
sex (or not) and why they use condoms
(or not), and the behavioral skills they
have to make healthy choices

4. Reasons to play sex: Social pressure
A desire for luxury items
―She told me that she loves that boy – that is
why she had sex with him. He takes care of
her… Like he can give her everything she
asks for... Like if she asks for clothes, he can
buy it for her. If she says let‘s go out, he does
not refuse, so they go out and enjoy. Like if
she wants money the boy can give her such
things.‖

5. Reasons to play sex: Social pressure
Peer pressure
―There is that peer influence.. Sometimes they
are being laughed at by their fellow friends.
There is that saying they have of,‗others are
doing it‘ and those who are doing it laugh at
those who are not doing it…how can you be
there without a boyfriend?‖

6. Reasons to play sex:
Decline of the Senga
―It may be difficult for the parents to talk
about sex with their children. [Sengas] are
people whom you think are able to talk with
your child… And when a young person sees
that old person, she will keep on following her.
…Traditionally, those are secret things. It is
really secret to tell your child about sex.‖

7. Reasons to play sex:
Barriers to condom use
 Overtly goes against a strong cultural
sanction against premarital sex.
 Cost (students do not have enough money)
 Embarrassment (being refused by the
shopkeeper)
 Misunderstanding of the effectiveness of
condoms
 “Bad manners” - it suggests suspicion of HIV
infection, and/or multiple concurrent
partnerships.

8. Reasons to play sex:
External locus of control
―like when one starts…to watch blue movies -
then you feel like you are the one doing it so
you feel attracted and then you are tempted
to go for it.‖

9. Reasons to play sex:
Sexual curiosity
―They say playing sex with a lady is very good
that you feel so much sweetness.‖

10. Reasons to play sex:
Sexual violence
―He can be having money and he will tell the
girl that [they should] go in town together to
cut hair, and when they reach there, you may
find that he has convinced the owner of the
salon to close her in the shop and they force
her to have sex.‖

11. Reasons not to play sex:
Knowledge of HIV transmission and
modes of prevention
―First and foremost you should avoid having
sex. Secondly, you should avoid sharing sharp
things to the people whether infected or not.
You can also go and have the test…If they
are a wife and husband and they go for a
test and they find that one of them is
infected, they can advise them to use a
condom.‖

12. Reasons not to play sex:
Knowledge of HIV transmission and
modes of prevention
Despite this, concerning inaccuracies –
particularly around anal sex - emerged:
…like in men you find that the man puts his
penis in the other‘s anus during sex and here
he may get the virus or not but is not at a big
risk compared to when he is having sex with
a woman. For a woman and a woman, these
may not get it because they use fingers.‖

13. Reasons not to play sex:
Moral injunction against playing sex
―If you go [to church] and read the Bible... like
when they talk about King David who had
sex with someone‘s wife and God punished
him by making his family commit other
crimes and even the death of his son. So
when you read such, you know that God does
not like that, so you avoid sex such that God
does not punish you.‖

14. Conclusions
 Like young people all over the world, youth
in Uganda are subjected to pressures to
engage in risky sex.
 Socio-cultural and economic influences
specific to Uganda may foster an
environment where social pressure to have
sex is particularly strong.
 HIV prevention programs should take
social, cultural and economic influences and
their complex interrelations into account.

15. FINDINGS FROMTHE
DEVELOPMENT SURVEY
DEVELOPING CYBERSENGA:
DATA INFORMINGTHE CONTENT

16. Methods
 In 2008-2009 we surveyed 5 schools:
◦ 1,508 surveys were completed
◦ 62% were male
◦ Youth ranged in age between 12-19+ years
 The aims were to: 1) quantify factors
related to HIV information, motivation, and
behavioral skills; 2) understand youth
profiles based upon their sexual history;
and 3) identify „popular opinion leaders‟

17. What do you use the Internet for?
57%
21%
58%
62%
21%
47%
0%
10%
20%
30%
40%
50%
60%
70%
Email Social networking
sites
Playing games
Males
Females
n=743

18. What do you SMS about?
77%
20%
42%
36%
18%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Sports Information about
health and disease
Latest news
Males
Females
n=405

19. What is your knowledge of HIV
prevention (incorrect answers)
24%
42%
24%
18%
51%
18%
0%
10%
20%
30%
40%
50%
60%
HIV/AIDS is
transmitted throgh
sperm/semen
If you know a
person well, you
don't have to use a
condom
HIV can go through
a condom
Male
Female

20. The local health center…
52%
63%
75%
40%
47%
60%
65%
48%50% 50%
69%
28%
37%
43%
62%
38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Keeps the
information private
Is easy to get to Treats you with
respect
Would give you
condoms if you
asked
Males, no sex
Males, had sex
Females, no sex
Females, had sex
All statistically significantly different across the four groups of youth p<0.05

21. Self esteem: positive aspects
65%
62%
39%
65%
56%
61%
39%
68%67%
63%
43%
69%
63% 60%
33%
61%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Satisfied with
myself
Have a number of
good qulities
I am a person of
worth
I am able to do
things well
Males, no sex
Males, had sex
Females, no sex
Females, had sex

22. Self esteem: negative aspects
9% 9%
77%
7%
20%
9%
74%
7%
16%
12%
78%
8%
29%
26%
76%
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
No good at all Feel useless
sometimes
Wish I could have
more respect for
myself
I am a failure
Males, no sex
Males, had sex
Females, no sex
Females, had sex

23. Health Concerns
0%
10%
20%
30%
40%
50%
60%
Your health Getting money Getting (someone)
pregnant
Parents' health
Males, no sex
Males, had sex
Females, no sex
Females, had sex
Very worried about…..
All statistically significantly different across the four groups of youth p<0.05

24. I‟m tired of hearing about HIV
prevention
14%
22%
17%
26%
0%
5%
10%
15%
20%
25%
30%
Males, no sex Males, had sex Females, no sex Females, had sex
Strongly agree

25. Top 3 things youth are interested in
hearing about
34%
40% 41% 42%
45%
54%
60% 61%
0%
10%
20%
30%
40%
50%
60%
70%

26. Attitudes about sex
17%
60%
79%
8%
58%
77%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Having sex before
marriage makes you a
better partner
You don't plan for sex; it
happens
You can't control your
urges with alcohol
Male
Female

27. Attitudes about coercive behavior
47%
58%
37%
48%
0%
10%
20%
30%
40%
50%
60%
70%
There's nothing you can say to a boy
who wants to play sex
Girls just want boys to buy them things
Male
Female

28. Attitudes about coercive behavior
47%
58%
37%
48%
0%
10%
20%
30%
40%
50%
60%
70%
There's nothing you can say to a boy
who wants to play sex
Girls just want boys to buy them things
Male
Female

29. Physical aggression in romantic
relationships
30%
38%
44%
39%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Hit, slapped, or phyiscally hurt by a
boy/girlfriend
Been hit, slapped, or phyiscally hurt by a
boy/girlfriend
Male
Female
Among youth who have had a boyfriend or girlfriend (n=786)

30. Gift giving to have sex*
28%
24%
18%
55%
0%
10%
20%
30%
40%
50%
60%
Given money, gifts, clothes, gifts so the
other person will have sex
Received money, gifts, clothes, gifts so
you will have sex
Male
Female
Among youth who have had sex (n=314; 327)

31. Percent of youth who have ever had
sex
20%
7%
42%
31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Males Females
Have never had sex
Have ever had sex

32. % of youth with sexual experience
by age and biological sex
0
21
24
33
39
47
37
64
6
9
16
19
28 28
37
40
0
10
20
30
40
50
60
70
12 13 14 15 16 17 18 19
Youth age (years)
Male (n=889)
Female (n=549)

33. Conclusions for design
 Given the popularity of online
games, games will be important for
engagement of youth
 Based upon the percent of boys who SMS
for information about sports, boys‟
content especially needs to include sports
themes

34. Conclusions for content
 We need to making sure that youth know HIV is
not small enough to get through a condom is
important.
 Also, we need to focus on changing norms to use
condoms with people youth know as well as do
not know well.
 Need to start changing norms for accessing
health services - especially for girls, giving
specific referral information.
 Females who have had sex seem to be
particularly in need of positive messaging. We
need to actively promote their self-worth.

35. Conclusions for content
 HIV prevention fatigue is high
◦ Need to focus on fundamentals of healthy
adolescence: problem solving, coping skills, etc
 Based upon what youth say they are interested
in:
◦ Teaching condom usage skills is not high on their
list, so need to „sell‟ the importance of it for
everyone
◦ General relationship skills are needed, e.g., how
do you end a relationship if it‟s not going well.
◦ Also, refusal skills are important: how do you
avoid sex – especially if you have played sex
before?

36. Conclusions for content
 Directly address boys‟ assumption that having sex
makes him a better man and a better husband.
 Talk about how drugs and alcohol impair
judgment but that youth still can control their
urges (they are responsible for their behavior).
 Gift giving is not uncommon to initiate a
relationship, but it seems to be particularly
common for girls who have had sex and should
likely be integrated into their scenarios.
 Need to change norms for physical violence
perpetration – particularly for girls.

37. SEXUAL COERCION IN
ADOLESCENTS:VOICES
FROMYOUNG PEOPLE A
DEVELOPING CYBERSENGA:
DATA INFORMINGTHE CONTENT
A Excerpts from: Birungi R, Nabembezi D, Kiwankua J, Ybarra
M, Bull S (2012).Adolescents‟ perceptions of sexual coercion in
Uganda. American. East African Journal of Public Health. 7(1): 58-63

38. Methods
 Three focus groups were conducted with
„popular opinion leaders‟ at partner schools
◦ Two groups were conducted with boys (n=13)
◦ One group was conducted with girls (n=7)
 All groups were asked the same questions
 The aim of the groups was to understand
youth‟s experience and perceptions of
coercive sex, and understand how we should
address this issue in the CS content

39. Verbal pressure is common
‗A situation may happen, like you are attending
a function and you spend a night there, and
when you are there in the night the boy tells
you that — I am badly off, you need to
help me — and you finally give in against
your will…you have come without the
intention of having sex, but you reach [there
and] the person starts demanding.‘

40. Coercion is perpetrated by adults
‗When you are having someone older than
you, you have to give respect to that person.
That person is going to fear the age of the
person, and then they will keep quiet.That is
where that kind of thing is going to come
from…‘

41. …but not by adolescents
‗For adolescents, for them they just fall in love with
each other, but I do not think that they are
forced.The forced sex I know is between the
adult and the young people.That one I know is
where there is forced sex.‘
A few disagreed however...
‗For me, what I think even there are some
adolescent boys who take girls to some
extent, they force them to have sex with them.‘

42. Men are perceived to be the
coercers, females the victims
‗You would rather go for girls rather than boys
because men have this mentality that these
young girls are not infected with HIV, and then
he wants to infect that girl.‘
‗For example, if you are talking to sugar mummies
and sugar daddies, you find that the information
[mostly] applies to girls; you should put more
emphasis on [the risks that young girls face
from men].‘

43. Coercion can be achieved through
gifts
‗In most cases you find the adult is the one
approaching the adolescents; like you find that
they give them small gifts like money and other
gifts in order to seduce these young people.‘
‗When someone gives you a gift, obviously that
person loves you, then, now you think that the
next thing has to be that [sex].You think that
okay this person has given me a gift because he
loves me, he cares about me, and now there are
two people in a relationship; you know that love
is sex — the next thing will be having sex.‘

44. Coercion can be achieved by
exploiting financial needs
‗Like you find the adult is assisting the
adolescent in some basic needs…. So you
find the adolescent plays sex with an adult so
that they can keep getting assistance from
the adults.‘

45. Coercion can be facilitated with
alcohol
‗Like you can be there and you get a girl, and
you get her booze and you convince her and
at the end of it all, you find that they are
drunk. So due to that influence of alcohol, you
find that they end up playing sex.‘

46. Coercion can be facilitated by adults
with authority over the youth
‗There was this girl who was staying with the
stepmother and the stepmother had a friend
who was a man.Those people had a belief
that sleeping with a young virgin girl can cure
AIDS.That man has AIDS and he was a close
friend to the stepmother. So the stepmother
decided to give her that one whose mother is
dead. She was then raped and she got
infected.‘

47. Victims are responsible too
‗I heard about a man who had a daughter. He
used to give her the boda boda man to take her
to school; so one time…the man had no time to
pick the girl from school, and he sent the boda
boda man to pick her [up], and the boda boda
man raped the girl.‘
Even the way girls wear [clothes] affects boys too
much…because when you see a girl putting on
a short skirt, it makes them feel like dying.‘

48. It is difficult to talk about (and
therefore report) rape
‗Okay when someone is your parent‘s
friend, your father will begin trusting him. He
can even trust him to take you to school, so
through that, the friend tells you something
and you wonder how you are going to tell
your father, so you just keep it and in the long
run you find yourself in a relationship.‘

49. Conclusions for content
 Help youth identify safe places to report
sexual violence
 Foster skills to think critically about the
intention behind gifts, and skills to refuse
unsafe gifts
 Address misconceptions:
◦ Both boys and girls can be perpetrators
◦ Adolescents can perpetrate and are more
likely to be involved than adults

50. Acknowledgements
 We would like to thank the entire
CyberSenga Study team from Center for
Innovative Public Health Research, Internet
Solutions for Kids – Uganda, Mbarara
University of Science andTechnology, the
University of Colorado, and Harvard
University, who contributed to the planning
and implementation of the study. Finally, we
thank the schools and the students their
time and willingness to participate in this
study.