Out of school female adolescent employment status and sexually transmitted infections (STIs) risk in Uganda: is it a plausible relationship?

Sexually Transmitted Infections (STIs) remain one of the major global sexual and reproductive health problems. Notably, adolescents aged 15–19 years form the second largest group, following 20–24 year olds, with the highest prevalence of STIs [1]. Approximately 20% of adolescents aged 15–19 years reported having STIs or symptoms of STIs in Uganda in 2011 [2]. If not addressed, STIs could lead to serious financial and health costs for both individuals and the wider public [3‐5]. Scholars have identified both risk and protective factors for STIs among adolescents; these factors include: adolescents’ sexual behaviours and practices [6], family–parental factors [7], socio-economic factors, and partner characteristics [1]. However the role of adolescent employment status as a potential protective or risk factor for STIs in Uganda has yet to be critically examined, despite the fact that many adolescents who drop out of school are engaged in work. Uganda Bureau of Statistics (UBOS) [8] estimated that approximately 60% of children aged 15–17 years were involved in some form of economic activity. Uganda Bureau of Statistics (UBOS) [8] further estimated that about 21% of females aged 14–17 were engaged in some form of work.

Many studies have assessed the relationship between employment and adolescents’ developmental outcomes such as schooling, grades at school, behaviour such as drug and alcohol consumption and emotional outcomes, but the relationship between employment and STI status has been overlooked. Three major contrasting arguments can be extracted from the literature: (1) there is no relationship between adolescent employment status and developmental outcomes [9‐12]; (2) work has a detrimental effect on adolescent behaviour and developmental outcomes [13‐17]; (3) adolescent employment correlates with positive developmental outcomes [18]. Moreover, how employment status may affect exposure to sexual behaviours and the potential risk of acquiring STIs for female adolescents, has received little attention. For example, Rich and Kim [16] studied the relationship between adolescents’ current employment status and timing of first sexual encounters and found that employment was associated with an increased likelihood of reporting an earlier first sexual encounter. However, Tenkorang, Rajulton and Maticka-Tyndale [19] found that unemployed youths experienced their first sexual intercourse earlier than their peers who were in employment. The contradictions make it difficult to draw a conclusive argument regarding the role of adolescents’ employment status on involvement in sexual activities and its possible impact on adolescents’ risk of STIs. Evidence exists to show that early sexual encounters are positively related to an increased risk of STIs [20‐22]. Evidence further shows that adolescents whose employment requires long hours of work (for example more than 120 h a month) or those who are intensely embedded in work were more likely than non-working adolescents to experience early sexual encounters. Another possible explanation for a link between employment and STIs is that adolescents who are employed may be exposed to other antisocial behaviours, such as drug and alcohol consumption, that could lead to risky sex and STIs [23]. It could also lead to increased association with peers who already exhibit behavioural problems. Mortimer [18] argues that self-selection effects may be evident in this group as adolescents who already exhibit problem behaviours may be more likely to be out of school and engaged in employment rather than their work experience directly contributing to an increased involvement in risky behaviours. Additionally, Mortimer [18] observed that earnings from work may be used to purchase alcohol and drugs. He goes on to argue that when differences in attitudes and behaviours are appropriately taken into account, the negative consequences of employment often disappear.

Adolescents’ sexual behaviours, partner characteristics, parental factors and socio-demographic factors are associated with adolescents STI status. Early sexual encounters have been found to be positively associated with increased odds of reporting of STIs or STI symptoms among adolescents in several studies [20‐22, 24]. For example, Kaestle, Halpern, Miller and Ford [21] reported that, STIs were higher among adolescents who experienced their first sexual encounter at age 13 when compared to those whose first sexual encounter was at 17 years.

Cumulative numbers of partners and multiple sexual partners have also been found to be positively associated with STIs among adolescents in many studies [23, 25, 26]. For example, Hahm, Lee, Ozonoff and Amodeo [26] found that sexual experience with more than one partner was significantly associated with positive STI diagnosis. Although, a cumulative number of sexual partners has been found to be strongly associated with the reporting of STIs, some other studies, for example, Santelli, Brener, Lowry, Bhatt and Zabin [23] pointed out that it could be mediated by other factors. However Forhan, Gottlieb, Sternberg, Xu, Datta, McQuillan, Berman and Markowitz [27] found a high prevalence of STIs among adolescents who reported only one lifetime sexual partner. They observed that STIs could be contracted soon after sexual initiation as female adolescents may not have the power to negotiate for safer sex. This is in line with the conclusion of Buffardi, Thomas, Holmes and Manhart [28], that contextual conditions which precede adolescents’ first sexual encounters could increase STI risk by increasing sexual risky behaviours and likelihood of exposure to infections.

Age difference between partners is also strongly associated with STIs among adolescents [25, 29‐32]. Gregson, Nyamukapa, Garnett, Manson, Zhuwau et al. [25] found that an older age of sexual partner was associated with increased risk of HIV-1 infection in both men and women but especially among young women whose partners were 5–10 years older. Differences in age of a partner could be mediated by other factors which precipitate the acquisition of STIs. For instance, adolescents are less likely to negotiate safe sex practices, such as condom use [33]. Drumright, Gorbach and Holmes [34] found that STIs were associated with partner’s having multiple sexual partners and ignorance about partner’s sexual behaviour. This study explores the relationship between out of school female adolescents’ employment status and STIs status.

The women’s individual recode file from the 2016 Uganda Demographic and Health Survey data (UDHS) was analysed to establish the relationship between female adolescents’ employment status and STI status. In the recode, out of a total of 18,506 women of reproductive age who were interviewed, 1444 adolescents aged 15–19 years reported that they had experienced their first sexual encounter; were sexually active in the year preceding the survey; and were out of school during the year of the survey. This sample of 1444 female adolescents was, selected as the final sample for this study. The sample of out of school female adolescents was selected because it represents a vulnerable population in several ways. This category of adolescents, have often dropped out of school due to poverty and other socio-cultural factors. These female adolescents are often left with no option but to marry at an early age or by force. Due to poverty, most female adolescents are likely to engage in risky sexual behaviours, such as transactional sex, and employment activities for economic survival. Additionally, the power dynamics involved make these adolescents more vulnerable as they have low decision-making power. All these factors pre-dispose them to the risk of STIs. For the overall DHS survey, the sampling was stratified by place of residence and clustered by enumeration areas. Thus, in order to account for the contextual effects of issues surrounding adolescent STIs, enumeration areas were controlled for in the multilevel analyses. There were 577 clusters or enumeration areas. The minimum number of respondents per cluster was one and the maximum was 12. The average number of respondents per cluster was three.

Descriptive analyses in Table 1 show that out of 1444 respondents, approximately 20% (N = 292) reported a positive STI status in the 12 months preceding the survey. Disaggregation by employment status shows that a third of the respondents (33.4%) were not working, 11.5% worked but received no payment, while 12% of the respondents worked in sales and services and approximately 4% were household or domestic workers.

This study’s objective was to understand the association between out of school female adolescents’ employment status and STI status in Uganda, controlling for female adolescents’ sexual behaviours and background characteristics. The results suggested that STI prevalence among out of school female adolescents was higher among the employed group than adolescents who did not work, excluding adolescents who worked as households/domestic employees, when the confounding factors were taken into account. The higher odds of reporting positive STIs were significant for female adolescents who worked but received no pay, were self-employed in agriculture, and for those who were engaged in manual work; which is in congruence with the study conducted by Rich and Kim [16]. However, this finding is in stark contradiction with other studies which highlight adolescent employment as a protective factor against STIs and risky sexual behaviours [19]. Without undermining the value of female adolescent employment [18], the increasing odds of reporting STIs among these female adolescents could be due to the heightened vulnerability of these groups of female adolescents. Their vulnerability may influence school dropout during adolescence and therefore weaken the protection against risky sexual behaviours and STIs schools provide to adolescent girls [35]. Yet adolescents’ psycho-social needs for a modern lifestyle (e.g. smart phone and data), may not be easily met by the jobs they do; this could increase their vulnerability to transactional sex and exposure to STIs [36]. Adolescents who work but do not receive pay, in addition to those who are self-employed in agriculture and in manual jobs receive little to no pay [37] which increases the vulnerability of these female adolescents. The low paying jobs could also expose the female adolescents to sexual exploitation that could increase the risk of STIs [38]. Thus the high level of vulnerability of out of school female adolescents who are in different types of employment exposes them to the risk of unsafe sex and STIs which is in accordance with other studies [39, 40]. This is perhaps because these female adolescents cannot negotiate for safer sex, hence an increased exposure to the risk of STIs [27]. The female adolescents who do not work could face similar vulnerability, however, the reduced risk of STIs could be attributed to the gains from parental monitoring [39], which is not possible for adolescents who may be working outside the home or away from parents. An alternative explanation could be, that adolescents who already have developmental problems may use work to gain access to behaviours that would be confined to only adults, including sexual behaviours and drug use, increasing exposure to peer groups that may lead them to engage in risky sex and STIs [36, 39]. Mortimer [18] argues that this could occur as a result of self-selection, however, the fact that adolescents who worked without receiving renumeration also reported increased odds of STIs suggests that their vulnerability over and above self-selection effects may be the reason for this relationship.

Apart from female adolescent employment status, number of lifetime sexual partners was an additional significant factor associated with female adolescents’ positive STI status. STIs were more prevalent among female adolescents who reported having had more than one lifetime sexual partner compared to those who had only one lifetime sexual partner, which is in agreement with other studies that stress that the cumulative number of sexual lifetime partners is a risky factor for adolescents STI transmission [23, 25, 26]. Likewise, the odds of reporting STIs were significantly higher among adolescents affiliated to the Pentecostal religion than for Catholics. This perhaps can be attributed to the fact that some people, including adolescents, join the Pentecostal religion in a quest for deliverance from the problems they face. The problems may include health problems, such as STIs/HIV, or behavioural problems which may include risky sexual behaviour. In contrast, the odds of reporting STIs were significantly lower among adolescents who lived in Teso, West Nile and Kigezi regions than in Kampala. Perhaps this is due to cultural reasons such as strong norms about sexual relationships for female adolescents or high level of exposure in Kampala which could lead the female adolescents to initiate sex early, hence increasing their exposure to STIs.

Out-of-school female adolescents who are employed in various types of low wage employments are at greater risk of exposure to STIs than their counterparts who do not work. Instead of being a protective factor against the risk of STIs, their employment could be a means of exposure to risky sexual behaviour and STIs given their vulnerability. These adolescents lack skills and are not empowered, hence may not be able to negotiate for improved wages or better working conditions. In the similar vein, they may not be in a position to negotiate for safe sex which exposes them to the risk of STIs.

This study recommends that opportunities for decent work should be provided to out of school female adolescents, which could enhance their acquisition of life skills, such as a sense of judgement, problem solving skills, competencies, self-worth and productive wages. Any employment opportunity that enhances female adolescents’ ability to acquire life skills, at the same time as providing a productive wage, could protect female adolescents against risky sexual encounters which may increase their exposure to STIs including HIV. Therefore, the provision of decent employment opportunities should be an avenue for instructional scaffolding for out of school female adolescents to build their life skills and become empowered. The areas for scaffolding should perhaps include resources and issues concerning reproductive health knowledge and practices among others. For adolescents who are engaged in employment and earn some income, they should be empowered in terms of knowing how best to spend their income in profitable investments rather than spending it on detrimental behaviours that could expose them to the risk of STIs.