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Evaluating the coverage of sexually transmitted infection prevention and control services in eight districts in Central Uganda: lot quality assurance sampling survey

BMC Infectious Diseases volume 25, Article number: 659 (2025) Cite this article

Abstract

Introduction

Sexually transmitted infections (STIs) are a major global public health problem, associated with infertility, adverse pregnancy outcomes, and significant social and economic burdens. These challenges are particularly severe in underprivileged communities. A 2024 World Health Organisation report highlighted a global surge in STIs, requiring intensified efforts to improve their control and management. In order to appropriately respond and reverse the status quo, it is important to understand the extent to which the current interventions have reached the beneficiaries. This study aimed to assess the coverage of sexually transmitted infection (STI) services using the Lot Quality Assurance Sampling (LQAS) approach in eight districts of Central Uganda.

Methodology

A household survey was conducted in eight districts, targeting four population groups: mothers of children aged 0–11 months, women aged 15–49 years, men aged 15 + years, and youth aged 15–25 years. LQAS was used, with each district stratified into five supervision areas (SAs). In each SA, 19 respondents were randomly sampled from each target group. The survey assessed key indicators related to STIs, including knowledge of STI symptoms, knowledge of actions to take when infected with an STI, and engagement in risky sexual behavior. The study also examined condom use during risky sex, circumcision acceptance and non-acceptance among men, including reasons for its acceptance or non-acceptance. Overall and district-specific coverage was calculated with 95% confidence intervals. Indicator coverage in the SAs was classified using LQAS decision rules (DRs) for each indicator, using the overall coverage as benchmark for setting the DR.

Results

The findings revealed that mothers of children aged 0–11 months demonstrated superior knowledge of STIs and appropriate actions to take if one has an STI. Men (15 + years) and youth (15–24 years) reported engaging more in risky sexual behavior compared to women 15–49 years and mothers of children aged 0–11 months. Relatedly, men 15 + years reported higher condom use during risky intercourse. Youth were more likely to be circumcised than older men. Coverage for most indicators varied across SAs and districts. However, one in forty of the SAs fell short of average coverage in all the indicators. Personal hygiene was the leading motivator for circumcision acceptance while fear of pain was the leading driver for refusal to accept being circumcised.

Conclusions

The findings highlight vital disparities in STI knowledge and risky sexual behavior among different demographic groups. These findings inform public health strategies to address STI disparities and improve reproductive health outcomes. District and SA-specific bottleneck analysis is recommended in order to provide actionable solutions to improve low-indicator coverage in low-coverage districts and SAs.

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Introduction

Sexually transmitted infections (STIs) pose significant public health problems including infertility, negative pregnancy outcomes, as well as creating substantial social and economic burdens to individuals globally. These challenges are more pronounced in underprivileged communities [1]. The World Health Organisation (WHO) reported a surge in STIs as a significant public health burden globally in a report released in 2024 [2]. The same report further highlighted that a total of 374 million new cases of curable STIs (syphilis, gonorrhoea, chlamydia and trichomoniasis) were reported among adults aged 15–49 years in 2020, with the number of new syphilis cases doubling by 2022 to 8 million. The low- and middle-income countries bear the biggest burden of STIs [3, 4]. STIs have a particularly high prevalence in Africa, accounting for 18% of global incidence [5]. Although demographic and health surveys in Uganda do not provide national-level data on the burden of STIs, some studies conducted in specific locations or among targeted groups indicate a high prevalence in the country. A study comparing STI prevalence between inland and fishing communities in Southern Uganda reported rates of 21% in inland areas and 31% in fishing communities [6].

Given the substantial impact that STIs have on global health, effective prevention and treatment strategies are imperative [7]. The burden of STIs on local resources escalates healthcare expenses, necessitating preventive strategies such as education and improved healthcare accessibility to overcome these challenges [8]. The increase in STI cases since the COVID-19 pandemic took over has been blamed on many countries focusing on the pandemic thus providing less preventive, testing, or treatment services [7]. As a result, there have been intensified public health efforts worldwide to ensure effective control and management of STIs [9].

Understanding the coverage and accessibility of STI prevention and control services plays a fundamental role in mitigating the spread of infections, promoting sexual health, and reducing associated morbidity and mortality [1]. Examining the extent and quality of STI services helps in gaining valuable insights into effectiveness of the STIs preventive measures, the adequacy of healthcare infrastructure, and the disparities that may exist in accessing essential healthcare services. It further empowers communities in the ongoing fight against the STIs burden and also informs policy decisions [10]. Public health managers who are aware of the services coverage of STI prevention and control service are in position to identify gaps, assess effectiveness, and plan services accordingly within their areas of practice [11]. Consequently, they can be in position to allocate resources efficiently, with targeted interventions thus leading to better services coverage and effectiveness.

The link between HIV/AIDS and STIs, which includes shared risk factors and challenges of co-infection, has been previously emphasized [12]. Preventing other (non-HIV) STIs reduces HIV transmission, enhances sexual health, promotes overall well-being, and improves health results. The prevention and control of both HIV/AIDS and STIs have the added advantages of stigma reduction and resource optimization [9]. The considerable resources allocated to HIV/AIDS prevention have also boosted efforts to prevent and control other STIs. As a result, the heightened emphasis on HIV/AIDS services worldwide has also increased efforts to improve prevention and control services for STIs [13]. Consequently, the need for robust assessment of the impact of the interventions to prevent both HIV/AIDS and STIs has demanded monitoring and evaluation of the initiatives put in place.

The WHO recommends stakeholders to provide information, education, and counseling in order to enhance individuals'awareness of STI symptoms, increase the chances of seeking care, and motivate their sexual partners to do the same as part of interventions to combat STIs [14]. In addition, the WHO recommends that health systems conduct surveillance, including collecting data on risk factors and intervention outcomes, to support evidence-based decision-making in STI prevention and control [15]. Most healthcare systems at various levels have heavily relied on health management information systems (HMIS) data generated at all health facilities for planning purposes [16]. However, the limitations of the HMIS data, predominantly generated from health facility-based therapeutic services means that vital community-centered information on prevention services is often missed [17, 18]. Nevertheless, non-HMIS data on STI service coverage provides valuable insights into service reach and highlights gaps in service delivery. The objective of this study was to assess the coverage of STI control services so as to provide guidance for improved planning, and includes coverage of HIV prevention using the safe male circumcision strategy. They study employed community-based household survey approach using the Lot Quality Assurance Sampling (LQAS) methodology. This information can then help to prioritize interventions, tailor interventions, monitor effectiveness, and optimize resource allocation to improve public health outcomes. Healthcare policymakers and service providers can use the study methods or its findings to evaluate their programs and services based on coverage gaps and community preferences, helping to enhance STI prevention efforts.

Methods

Study design

An LQAS survey was conducted between February and March 2022 in eight districts of Cantral Uganda that include Mubende, Kasanda, Mityana, Kiboga, Kyankwanzi, Luwero, Nakaseke, and Nakasongola. LQAS is a methodology used to monitor and evaluate programmes and services. The LQAS methodology has for more than two decades, been used to assess delivery of, among many other public health services, the adherence to policies and standard guidelines, HIV/AIDS, maternal and child health services, including coverage and quality of immunization, nutrition, diarrhea, and malaria [18, 19]. By conducting this assessment alongside district personnel, the objective was to familiarize them with a methodology, offering immediate, detailed insights into STIs service delivery. This facilitates prompt decision-making, eliminating the need to rely solely on periodically conducted demographic health surveys, which often entail delays in data provision. Besides this, several other reasons influenced the use of LQAS for this assessment.

First, LQAS’s cost-effectiveness, enables more frequent data collection and continuous monitoring. The LQAS approach also uses small sample sizes enabling timely estimations and providing insights at the district and local level. Besides, LQAS’s implementation is straightforward, as it doesn't require complex statistical calculations and expertise that the nationally conducted demographic health surveys would require. By focusing on specific service indicators, LQAS fosters tailored interventions, facilitates informed decision-making, targeted interventions, and prompt corrective actions. One of the strengths of the LQAS methodology is its ability to provide coverage information at decentralized or sub-district levels such as the supervision area (SA), enabling local health managers to access data at the lowest levels of the health system, which other methods may not offer [20]. We chose the LQAS approach so that the information can be used to generate local solutions for improving STI programming based on differences within SAs or sub-counties in the districts.

LQAS entails dividing a population or area into smaller groups called lots (SA’s) and selecting a predetermined number of units from each lot [21]. An SA is a specific geographical or administrative subunit within a larger district or region used for monitoring and evaluation purposes [22]. SAs are smaller and more manageable in terms of data collection and analysis [23]. Coverage of services for each of the SA, district or for the overall catchment area (all the eight districts combined) can specifically be assessed for each of the indicators. Since LQAS allows for targeted evaluations and intervention for corrective action at the SA level, each district was divided into five SAs as shown in Table 1.

Table 1 Survey districts and SAs
Full size table

A total of 40 SAs were created which were labeled from A to AO. The SAs were formed by merging sub-counties or town councils in rural areas and divisions of municipalities in urban areas. Each SA represents a distinct subset of the population and is used to assess the performance or coverage of specific indicators within that area [24]. This enables decision-makers to identify areas of concern and take appropriate actions to address any issues or gaps in service delivery.

The sample size was calculated using the classical LQAS with an upper threshold of 80% and lower threshold of 50%. A classical LQAS considers an SA to have satisfactory performance of an indicator if it achieves 80% or higher. An SA's performance is considered unsatisfactory if the results of a specific indicator fall below 50%. In mixed-status performance, SA results fall between the lower (50%) and upper (80%) benchmarks [25]. The α and β errors each do not exceed 10%, with resulting sample size of 19 individuals from each SA. This sampling technique reduces errors while maintaining an acceptable level of precision [26].

The probability proportionate to size (PPS) sampling approach was used to select 19 interview locations from each SA. The 2014 Uganda National Housing and Population Census data was used for the PPS sampling. Interviews were conducted with four groups of respondents: mothers of children aged 0–11 months, women aged 15–49 years, men aged 15 years and above (15 + years), and youths aged 15–24 years. In each district, 95 respondents were randomly sampled and interviewed from each group, resulting in a district-level total of 380 respondents and an overall total of 3,040 respondents.

Regarding inclusion, persons who met the age and sex criteria for the study’s respondent groups were included in this study. Specifically for the mothers of children aged 0–11 months questionnaire, only women with children within this age group were included. Persons who did not meet the age or sex criteria for a particular questionnaire/target group were excluded for the questionnaire in reference. In addition, persons 18 years or older, mature minors and emancipated minors who did not consent to participate were excluded. Regarding minors who were neither emancipated nor mature, those who did not assent or whose parent did not consent to participate in this study were excluded. Visitors were also excluded. We defined a visitor as someone who has lived in the SA for less than six months. Finally, a sampled household member who was not in the household by the time of data collection visit, and could not be accessed within 30 min was excluded.

Data collection

To determine the starting household in each interview location, segmentation sampling was utilised. The data collector created a village map with the assistance of a village guide. A parallel sampling strategy was employed, using an index random starting household to select respondents by proceeding to the"next nearest"household until the set of four questionnaires were completed. Only one questionnaire set in each interview location was administered to minimize clustering and reduce the survey design effect to approximately one. Each respondent group completed an interviewer-administered questionnaire designed for this study that collected information on knowledge of STIs, sexual behavior, condom use, and circumcision (only for men aged 15 years and above) in each interview location. Data were collected electronically and uploaded daily, with duplicate uploads and field entry errors checked. Every day, errors were fixed. The investigators worked in pairs to clean the data. Data was collected based on several constructs for each demographic group as explained henceforth.

To assess their knowledge of how STIs manifest in men and women, mothers of children 0–11 months, youth 15–24 years, women 15–49 years, and men 15 + years were asked to mention signs and symptoms of STIs among men and women. Sexual behavior and condom use were assessed by asking youth 15–24 years, women 15–49 years, and men 15 + years about their sexual behavior in the previous 12 months, specifically whether they had sexual intercourse with a non-regular partner. Furthermore, we asked whether or not the respondent used a condom during sexual intercourse with a non-regular partner. Regarding sexual behaviour and condom use, the following indicators were examined; (i) Percentage of youths 15–24 years who have ever had sexual intercourse (ii) Percentage of youths 15–24 years who perceive low or no risk of getting HIV/AIDS infection; (iii) Percentage of respondents who had sex with more than one sexual partner in the last 12 months (iv) Percentage of sexually active (unmarried/non-cohabiting) youth 15–24 years who have ever used a condom; (v) Percentage of respondents (women 15–49 years, youth 15–24 years and men 15 + years) who had sex with more than one sexual partner in the last 12 months; (vi) Percentage of respondents (women 15–49 years, youths 15–24 years, men 15–49 years) who used a condom during the last act of sexual intercourse with a non-marital or non-cohabiting sexual partner in the last 12 months. In order to assess the percentage of youths 15–24 years who perceive low or no risk of getting HIV/AIDS infection, the youth were asked the question, “how do you consider yourself in terms of the risk of acquiring HIV?”. The available options were; high risk, low risk, no risk, I am HIV positive or don’t know. Those who mentioned ‘low risk or no risk’ were classified as perceiving themselves as being at low or no risk of HIV acquisition.

We assessed the coverage of uptake of circumcision services and found out reasons for its acceptance or non-acceptance among men aged 15 + years. The rationale for doing so was that circumcision reduces the risk of certain STIs like HIV, HSV-2, and HPV. By assessing its coverage, acceptance and non-acceptance we aimed at gauging service utilisation and identify access gaps thus obtaining information that could guide in tailoring interventions as an additional STI preventive measure, impacting public health response. Therefore, we conducted an inquiry into the factors influencing the acceptance of circumcision among males aged 15 + years. Reasons for accepting circumcision were examined, including religious and cultural factors, risk reduction for HIV transmission, personal hygiene considerations, and any additional rationales provided. Additionally, youth 15–24 years and men 15 + years who were not circumcised were asked the main reason they are not circumcised. Factors considered included; uncertainty regarding where and when to undergo circumcision, financial constraints due to high cost, absence of available circumcision services, lack of trust in healthcare providers, geographical barriers to accessing circumcision facilities, apprehension about pain and potential sexual consequences, concerns about reduced sexual performance, satisfaction or desire, fear of contracting infections, uncertainty regarding the benefits, and other factors elucidated by participants.

Quality control

During LQAS training, a full-day field-practicum session was conducted to pre-test data collection tools and pilot the survey process using Android devices. Data collectors, proficient in English and Luganda, were trained in a three-day workshop before deployment to the field. Supervisors from each district ensured sampling and interview accuracy through regular visits. Data completeness, consistency, and appropriateness were monitored daily, and ineligible respondents were excluded. In case of any issues, data collection plans were developed, supervised, and verified by district-based supervisors and working together with the authors.

Data analysis

For all of the agreed-upon survey indicators, two levels of analysis were conducted. In the first level, data from all the SAs was pooled to calculate the coverage proportion (percent) in each district, and for the entire study area with the corresponding 95% confidence intervals. The coverage proportion for an indicator in a district refers to the proportion or percentage of the target population within that district that has the required knowledge, received the service or practiced a health behaviour that is being assessed for that specific indicator [27]. The coverage estimates were weighted by the size of the SA population. Overall project-level coverage refers to the proportion or percentage of the target population that has the trait of interest (such as knowledge of STI prevention), calculated by aggregating the data from all the eight districts for a particular indicator. The second level of analysis involved SA-classification in order to identify priority SAs that are in most need of support using the LQAS decision rule (DR). The DR is a predetermined threshold for classifying indicators according to their performance or coverage within a given SA [28]. In this study, the DR was set using the project's average coverage as our benchmark for classifying coverage of SAs for each indicator. We used the LQAS table of DRs for setting the DRs.

A 95% confidence interval was computed for each indicator's coverage outcomes. This facilitated the comparison of district performance both internally and in contrast to the overall performance across the entire catchment area comprising eight districts. If the confidence intervals overlapped, it indicated no statistically significant difference in coverage for that indicator across demographic groups (considering all assessed demographics) within each district. A non-overlap indicated a statistically significant difference. Moreover, in addition to examining circumcision service coverage, analytical maps were utilized to offer essential insights into the performance levels of SAs, essentially delineating local service areas that were either excelling or falling short.

A respondent was considered knowledgeable about signs and symptoms of STIs in women if he or she could name at least two signs or symptoms of STIs in women. Similarly, any respondent who could name at least two STI symptoms or signs in men was considered knowledgeable about STI symptoms or signs in men. We calculated the proportion (%) of respondents who knew the signs and symptoms of STIs among women and men for each respondent group at the project and district levels. Furthermore, we classified the SA-level coverage of those who were knowledgeable using DR, with the project-level coverage serving as the benchmark for each indicator. Knowledge of what to do if one has an STI was also evaluated by classifying respondents able to correctly mention at least two actions to take as knowledgeable, or otherwise, not knowledgeable.

Results

Characteristics of the respondents and response rate

Table 2 presents the characteristics of respondents. Across all districts, 760 respondents were sampled for each demographic group; mothers of children aged 0–11 months, youth aged 15–24 years, women aged 15–49 years, and men aged 15 + years. This corresponds to 95 respondents per district for each group, with 19 respondents from each SA per group. The total sample size across all respondent categories was 3,040 respondents. Accordingly, the study response rate was 100%. The highest proportion (29.1%) of mothers of children aged 0–11 months were in the 20–24 years age category, followed by those aged 25–29 years (26.1%) and 30–34 years (18.7%). Among women aged 15–49 years, the highest proportion (22.6%) fell within the 30–34 age group, followed by 25–29 years (21.4%), 20–24 years (14.8%), 40–44 years (14.6%), and 35–39 years (13.6%). In the men 15 + years group, the most respondents were in the age groups of 30–34 years (19.1%), followed by 50 + years (15.0%), 35–39 years (14.3%), and 20–24 years and 25–29 years, each at 12.9%. Among youth aged 15–24 years, categorized into below 20 years and 20–24 years, the latter constituted the majority with 60.3% of the respondents.

Table 2 Characteristics of respondents
Full size table

Regarding marital status, the majority of each of mothers of children aged 0–11 months (53.3%) and men aged 15 + years (50.0%) were married. Only 10.1% of youth aged 15–24 years were married, while nearly half (48.6%) of women aged 15–49 years were married. Majority, 54.1% of the youth aged 15–24 years were single, with no partner. The 31.1% of mothers of children aged 0–11 months, 23.5% of women aged 15–49 years, and 23.2% of men aged 15 + years were in cohabiting relationships. Cohabitation was the second most common marital status in these groups, following marriage.

Across all the respondent groups, most had incomplete or complete primary education. The 31.5% of mothers of children aged 0–11 months, 24.5% of youth aged 15–24 years, 27.4% of women aged 15–49 years, and 28.6% of men aged 15 + years had complete primary education as their highest education attainment. On the other hand, 28.2%, 24.1%, 32.1% and 29.3% of mothers of children aged 0–11 months, youth aged 15–24 years, women aged 15–49 years and men aged 15 + years had incomplete primary education as the highest level of education attained respectively. These findings imply that majority of the respondents in each of the four categories had complete or incomplete primary education.

Knowledge about STIs

Shows the estimates of coverage in STI knowledge indicators and their 95% confidence intervals.

Table 3 District-level and overall coverage in knowledge of STI signs and symptoms, and knowledge of actions to take when one has an STI
Full size table

The knowledge of signs and symptoms of STIs in women

Mothers of children aged 0–11 months demonstrated the highest and statistically significant knowledge of at least two common signs or symptoms of STIs in women, with a proportion of 79.5% (95% CI: 76.7–82.4), compared to men aged 15 + years, youth aged 15–24 years, and women aged 15–49 years. The 70.8% (95% CI: 67.6–74.0) of women aged 15–49 years, 58.3% (95% CI: 54.8–61.8) of men aged 15 + years and 44.7% (95% CI: 41.2–48.2) of youth aged 15–24 years knew at least two signs or symptoms of STIs in women. Nonetheless, the ability of mothers of children aged 0–11 months to correctly identify these signs or symptoms varied across districts, ranging from 58.1% (95% CI: 48.0–68.2) in Nakaseke to 94.4% (95% CI: 89.6–99.1) in Kiboga. Additionally, districts such as Kyankwanzi (71.2% [95%CI: 62.0–80.5]), Mityana (72.9% [95%CI: 63.7–82.0]), and Mubende (78.0% [95%CI: 69.5–86.5]) had proportions that are lower than the average coverage for mothers of children aged 0–11 months who are able to identify at least two STI signs or symptoms in women.

The proportion of youths aged 15–24 years who correctly recognized at least two signs or symptoms of STIs in women varied across different districts, ranging from 17.6% (95% CI: 9.8–25.3) in Nakaseke to 61.6% (95% CI: 51.6–71.5) in Mubende. Among youth aged 15–24 years with knowledge of signs and symptoms of STIs in women, several other districts had lower proportions than the average coverage. These include Kyankwanzi at 42.7% (95% CI: 32.6–52.8), Luwero at 28.3% (95% CI: 19.1–37.5), Mityana at 43.7% (95% CI: 33.5–53.8), and Nakasongola at 43.8% (95% CI: 33.6–54.0).

The proportion of women aged 15–49 years who correctly recognized at least two common signs or symptoms of STIs in women also had disparities between districts, ranging from 57.4% in Nakaseke to 86.1% in Kasanda. Two additional districts, including Luwero at 62.1% (95%CI: 52.1–72.1) and Mityana at 62.3% (95%CI: 52.4–72.2) had lower proportions than the average coverage, of women aged 15–49 years who can correctly identify at least two signs or symptoms of STIs in women.

The proportion of men aged 15 + years who correctly identified at least two signs or symptoms of STIs in women ranged from 40.3% (95% CI: 30.2–50.3) in Nakaseke to 72.5% (95% CI: 63.4–81.7) in Kasanda. Two additional districts, including Kyankwanzi at 53.2% (95%CI: 43.0–63.4) and Luwero at 48.7% (95%CI: 38.4–58.9) had lower proportions than average coverage, of men aged 15 + years who correctly identified at least two signs or symptoms of STIs in women.

The knowledge of signs or symptoms of STIs in men

Across all demographic groups, the knowledge of signs and symptoms of STIs among men fell below 80% optimum performance level. Nonetheless, men aged 15 + years (59.7%, 95%CI: 56.2–63.2) and mothers of children aged 0–11 months (59.0%, 95%CI: 55.5–62.5) had the highest proportions of respondents able to identify at least two signs or symptoms of STIs in men, while women aged 15–49 years (53.9%, 95% CI: 50.3–57.4) and youth aged 15–24 years (50.8%, 95%CI: 47.2–54.3) displayed comparatively lower levels of knowledge.

The proportion of mothers of children aged 0–11 months who correctly identified at least two common signs or symptoms of STIs in men ranged from 36.5% (95% CI: 26.6–46.3) in Nakaseke to 73.0% (95% CI: 63.9–82.1) in Kiboga. The other districts with lower coverage than the average, of mothers of children 0–11 months who correctly identified at least two common signs or symptoms of STIs in men are Kyankwanzi, 54.4% (95%CI: 44.2–64.6), Luwero, 56.8% (95%CI: 46.6–66.9), and Mubende, 56.0% (95%CI: 45.8–66.1).

The proportion of youth aged 15–24 who correctly identified at least two common signs or symptoms of STIs in men ranged from 29.0% (95% CI: 19.7–38.3) in Nakaseke to 68.5% (95% CI: 59.0–78.0) in Kiboga. Luwero, at 32.6% (95% CI: 23.0–42.2) is the other district whose coverage of youth 15–24 years who correctly identified at least two signs or symptoms of STIs in men is lower than the average coverage.

The proportion of women aged 15–49 years who correctly identified at least two common signs or symptoms of STIs in men ranged from 35.8% (95% CI: 26.0–45.6) in Nakaseke to 80.9% (72.9–89.0) in Kiboga. At 40.5% (95% CI: 30.3–50.7), Luwero is the other district whose coverage of women 15–49 years who correctly identified at least two common signs or symptoms of STIs in men is lower than the project level average.

Finally, the proportion of men 15 + years who correctly identified at least two common signs or symptoms of STIs in men ranged from 34.8% (95% CI: 25.0–44.5) in Nakaseke to 77.3% (95% CI: 68.8–85.9) in Kiboga. Other districts with lower coverage than the average, of men 15 + years who correctly identified at least two common signs or symptoms of STIs in men are Kyankwanzi (55.6% (95%CI: 45.4–65.7), Luwero (55.9% (95%CI: 45.7–66.0), and Nakasongola (54.6% (95%CI: 44.4–64.8) (Table 3).

SA-level classification of respondents who correctly identify at least two common signs or symptoms of STIs in women and men

Table 4 outlines the findings at the SA level for every demographic group studied, specifically in correctly identifying at least two common signs or symptoms of STIs in women and men.

Table 4 SA-level coverage of respondents who can identify at least two signs or symptoms of STIs in women and men
Full size table

Regarding mothers of children aged 0–11 months who accurately identified at least two signs or symptoms of STIs in women, in each of Kyankwanzi and Mityana districts one out of the five SAs fell short of the DR. Two of the five SAs in Mubende, three of the five SAs in Nakaseke did not attain the DR of 13. This means these SAs had their coverage below the average coverage threshold of 79.5% (approximately 80.0%) regarding mothers of children aged 0–11 months who identified at least two signs or symptoms of STIs in women. For the same demographic group of mothers of children aged 0–11 months who correctly identified at least two signs or symptoms of STIs in women, none of the SAs in each of Kasanda, Kiboga, Luwero, and Nakasongola districts fell short of the DR. Pertaining to mothers of children aged 0–11 months who accurately identified at least two signs or symptoms of STIs in men, in each of the districts of Kasanda, Kyankwanzi, Mityana, and Mubende, one out of the five SAs, two SAs in Luwero, and three SAs in Nakaseke failed to meet the DR of 9, depicting a coverage below the average of 59.0% (approximately 60.0%) in these SAs. None of the SAs in the districts of Kiboga and Nakasongola fell short of the DR regarding mothers of children aged 0–11 months who correctly identified at least two signs or symptoms of STIs in men.

Regarding youth aged 15–24 who correctly identified at least two signs or symptoms of STIs in women, one out of the five SAs in each of Kiboga, Mityana, Nakasongola, and Kyankwanzi, and two SAs each in Luwero and Nakaseke districts did not achieve the DR. Accordingly, they fell short of the average coverage of 44.7% (approximately 50.0%). All the SAs in each of Kasanda and Mubende districts achieved the DR regarding youth aged 15–24 correctly identifying at least two signs or symptoms of STIs in women. Concerning the awareness of at least two signs or symptoms of STIs in men among youth aged 15–24 years, one out of the five SAs in each of Kasanda and Mityana districts, two SAs in each of Kiboga, Kyankwanzi, and Luwero districts, and three SAs in Nakaseke did not reach the DR. Consequently, they fell short of the 50.8% (approximately 55%) average coverage. All the SAs in Mubende and Nakasongola districts achieved the DR regarding the youth 15–24 years who correctly identified at least two signs or symptoms of STIs in men.

For women aged 15–49 years who correctly identified at least two signs or symptoms of STI’s in women, one out of the five SAs in in Luwero, three out of five SAs in Mityana, and four out of five SAs in Nakaseke did not attain the DR of 12, thus falling short of the 70.8% (≈75.0%) average coverage. All the SAs in each of Kasanda, Kiboga, Kyankwanzi, Mubende and Nakasongola districts achieved the DR regarding women aged 15–49 years who correctly identified at least two signs or symptoms of STIs in women. In the districts of Luwero and Mityana, among women aged 15–49 who accurately identified at least two signs or symptoms of STIs in men, the DR of 8 was not met in one of the five SAs while in Nakaseke district, two of the SAs also did not achieve the DR, thus falling short of the 53.9% (≈55.0%) average coverage. All the SAs in each of Kasanda, Kiboga, Kyankwanzi, Mubende and Nakasongola districts achieved the DR regarding the women aged 15–49 years who correctly identified at least two signs or symptoms of STIs in men.

For men aged 15 + years who accurately identified at least two signs or symptoms of STIs in women, the SAs in various districts, including one out five in each of Kiboga, Kyankwanzi, and Mubende districts, two out of five in Luwero, and three in Nakaseke districts, did not achieve the DR of 9. This means they are short of the average coverage of 58.3% (≈60.0%). However, in Kasanda, Mityana, and Nakasongola districts, all SAs met the required DR. Similarly, for men aged 15 + years who correctly identified at least two signs or symptoms of STIs in men, one of the five SAs in each of Kyankwanzi and Nakaseke districts, did not attain the DR of 9, thus falling short of the average coverage of 59.7% (≈60.0%). All the SAs in each of Kasanda, Kiboga, Luwero, Mityana, Mubende, and Nakasongola districts met the DR for this indicator.

Knowledge of action(s) to take in case of an STI

Table 3 also reveals the proportion of respondents who were aware of at least two correct actions to undertake in the event of contracting an STI. The percentages varied in in the following descending order: 50.5% (95%CI: 46.9–54.0) among mothers of children aged 0–11 months, 43.5% (95%CI: 39.9–47.0) among women aged 15–49 years, 40.0% (95%CI: 36.5–43.5) among men aged 15 + years, and 31.7% (95%CI: 28.4–35.1) among youth aged 15–24 years.

Throughout all the districts, the percentages of mothers of children aged 0–11 months who were aware of at least two steps to take if they contracted an STI ranged from 34.0% (95% CI: 24.3–43.7) in Nakaseke to 74.5% (95% CI: 65.6–83.5) in Kyankwanzi. Additionally, Luwero, at 49.2% (95%CI: 39.0–59.4), Mubende, at 42.0% (95%CI: 31.9–52.1), and Nakasongola, at 41.8% (95%CI: 31.7–51.9), had proportions below the average coverage of 50.5% (95%CI: 46.9–54.0) for mothers of children aged 0–11 months with knowledge of at least two actions to take in case of an STI.

For youth aged 15–24 years, the percentage of those aware of at least two steps to take if they contracted an STI ranged from 11.9% (95% CI: 5.2–18.5) in Luwero to 66.6% (95% CI: 56.9–76.2) in Kyankwanzi. Nakaseke, at 14.1% (95%CI: 7.0–21.2), Mubende, at 30.0% (95%CI: 20.6–39.4), and Nakasongola, at 26.9% (95%CI: 17.8–35.9), had proportions below the average coverage for youth aged 15–24 years with knowledge of at least two actions to take if they suspected having an STI.

The proportion of women 15–49 years who knew at least two actions to take if they had an STI ranged from 23.0% (95% CI: 14.4–31.6) in Nakaseke to 61.9% (95% CI: 52.0–71.9) in Kasanda. Other districts with lower coverage than the average, of women 15–49 years who knew at least two actions to take if they had an STI are Luwero (28.4% [95% CI: 19.1–37.8]), Mubende (37.6% [95% CI: 27.7–47.5]), and Nakasongola (32.0% [95% CI: 22.4–41.6]).

In men aged 15 + years, awareness of STI management varied across districts, with Nakaseke having the lowest proportion at 18.7% (95% CI: 10.7–26.6%) and Kasanda the highest at 64.5% (95% CI: 54.7–74.3%). Luwero and Nakasongola with 21.1% (95% CI: 12.8–29.5%) and 24.6% (95% CI:15.8–33.4%) respectively, had lower coverage compared to the average coverage of 40.0% (95% CI: 36.5–43.5%) for this indicator.

SA-level classification of coverage of responds who know at least two actions to take when one has an STI

Table 5 outlines the performance levels of SAs regarding respondents'knowledge of at least two actions to take when someone has an STI.

Table 5 SA-level coverage of respondents who correctly identify at least two actions to take in case one has an STI
Full size table

Among mothers of children aged 0–11 months who were knowledgeable about at least two actions to take if they had an STI, one SA in each of Kasanda, Luwero, and Mityana districts, two of the five SAs in Kiboga district, and three of the five SAs in each of Mubende, Nakasongola, and Nakaseke districts failed to reach the DR of 8, thus falling below the 50.5% coverage (≈55.0%). Only Kyankwanzi district had all its SAs attain the DR for this indicator in this demographic group.

Among youth aged 15–24 years who were aware of at least two actions to take if one had an STI, one of the five SAs in each of Kasanda and Luwero districts, two of the five SAs in each of Nakaseke and Nakasongola districts, and three of the five SAs in each of Kiboga and Luwero districts failed to attain the DR of 4, thus falling below the average coverage of 31.7% (≈35.0%). The districts of Kyankwanzi, Mityana and Mubende each had all their five SAs attain the DR in this indicator in this demographic group.

In terms of SA performance concerning women aged 15–49 who were knowledgeable about at least two actions to take if one had an STI, one of the five SAs in Kiboga district, and two of the five SAs in each of Luwero, Mubende, Nakaseke, and Nakasongola districts failed to achieve the DR of 6, falling short of the average coverage of 43.5% (≈45.0%). However, in each of Kasanda, Kyankwanzi, and Mityana districts, all SAs attained the DR.

Regarding men aged 15 + years who were aware of at least two actions to take if one had an STI, one of the five SAs in Kiboga, two of the five SAs in each of Nakaseke and Nakasongola districts, and four of the five SAs in Luwero did not achieve the DR of 5, falling short of the average coverage of 40.0%. Conversely, in the districts of Kyankwanzi, Kasanda, Mityana, and Mubende each had all their five SAs attain the DR.

Sexual behavior and condom use

Sexual behaviour among youth aged 15–24 years

The findings on sexual behavior and condom use are summarized in Table 6. Up to 60.2% (95% CI: 55.5–65.0) of youth aged 15–24 years have ever had sexual intercourse. Youth aged 15–24 who have had sex at least once are spread fairly evenly across different districts, albeit with some notable exceptions. Mubende district (77.7%) particularly has had a higher proportion than the average, of youths who have had sex, while Nakaseke and Nakasongola districts have lower proportions of youth who have had sex. Nakaseke district's proportion of 24.3 (95% CI: (2.0–36.6) is significantly lower than the average proportion of youth aged 15–24 years who reported to have had sex.

Table 6 District-level and overall coverage in sexual behaviour and condom use indicators
Full size table

Only 59.2% (95% CI: 55.2–63.2) of the youth who have ever had sexual intercourse at some point in their lives (were sexually active) have used a condom at some point. In addition, there exists significant divergence among districts regarding the proportion of youth who have ever used a condom, ranging from 41.6% (95% CI: 30.9–52.3) in Mubende to 70.7% (95%CI: 60.3–81.1) in Luwero district. Furthermore, only about 1 in 4 (26.7%, [95% CI: 20.1–33.4]) of the youth who had sex with a non-marital or non-cohabiting sexual partner in the past 12 months used a condom during their most recent sexual encounter. At least 15.7% (95% CI: 10.4–20.9) of the youths aged 15–24 years reported having sex with multiple partners in the past year. In general, youth aged 15–24 years were less likely to use condoms with non-marital or non-cohabiting sexual partners in the 12 months prior to the survey compared to men aged 15 + year as well as women aged 15 to 49 years, and the observed difference is statistically significant. There exist significant differences among districts regarding condom use during their last sexual encounter with non-marital or non-cohabiting sexual partners in the 12 months prior to the survey among the youth aged 15–24 years, ranging from 4.8% (95%CI: −4.2–13.8) in Luwero to 63.8% (95%CI: 44.0–83.6) in Kyankwanzi. Youth in Kasanda, Kiboga, and Luwero districts have particularly had higher rates of sexual intercourse and lower rates of condom use.

Overall, at 69.3% (95% CI: 66.0–72.6), percentage of youth who perceive low or no risk of getting HIV/AIDS infection is high. A notably higher proportion of 91.6% (95% CI: 86.0% to 97.3%) of the youth in Nakasongola district perceive low risk, significantly above the average estimate. Conversely, youth in Mubende (52.8% (95% CI: 42.6–63.0), Kyankwanzi (56.2%, 95% CI: 46.0%66.3%) and Nakaseke districts have had lower perceptions of risk of HIV/AIDS.

Sexual behaviour among women and men

A significant gender gap emerges regarding having sex with multiple partners in the last 12 months. Among men aged 15 + years, 35.2% (95% CI: 31.3–39.2) reported having sex with more than one partner, whereas only 11.0% (95% CI: 8.4–13.6) of women aged 15–49 years did so. At 76.7% (95% CI: 71.7–81.7), condom use during the most recent high-risk sexual encounter (sexual intercourse with a non-marital or non-cohabiting sexual partner in the last 12 months) is significantly higher among men 15 + years compared to women 15–49 years (51.4%; 95% CI: 43.1–59.7). Men in all districts have had higher rates of condom use compared to women. Condom use among women aged 15–49 varies across districts, with Luwero (30.8% [95% CI: −6.9–68.4]) and Nakaseke (20.8% [95% CI: −4.8–46.3]), particularly having low rates.

Safe male circumcision coverage

Figures 1 and 2 respectively show the proportions of youth 15–24 years and men 15 + years who were circumcised in the districts. Overall, 68.6% (95% CI: 64.0–73.1) of youth aged 15–24 years were circumcised, with lowest coverage in Nakaseke (39.9%; 95% CI: 25.2–54.6) and highest in Mityana (81.6%; 95% CI: 72.7–90.4). In addition to Nakaseke, Kyankwanzi (46.9%; 95% CI: 33.5–60.2) and Nakasongola (67.0%; 95% CI: 52.6–81.5) districts had lower rates than the average coverage. Overall, 58.8% (95% CI: 55.3–62.3) of men 15 + years were circumcised. The proportion of men 15 + years who were circumcised was lowest in Nakasongola, at 41.6% (95% CI: 31.5–65.0), and highest in Mubende, at 67.1% (95% CI: 57.5–76.8). Aside from Nakasongola, Kasanda, 55.3% (95% CI: 45.1–65.4) and Nakaseke, 54.8% (95% CI: 44.6–65.0) had lower coverage than the overall average coverage.

Fig. 1
figure 1

District-level coverage of male youth 15–24 years who are circumcised. Legend  District coverage ≥ the average coverage of 68.6%.  District coverage ˂ the average coverage of 68.6%

Full size image
Fig. 2
figure 2

District-level coverage of men 15+ years who are circumcised. Legend  District coverage ≥ the average coverage of 58.8%.  District coverage ˂ the average coverage of 58.8%

Full size image

Reasons for circumcision

Table 7 summarises the reasons behind circumcision among male youth aged 15–24 years and men aged 15 + years. The most of respondents (55.9% of male youth and 42.4% of men) accepted circumcision for personal hygiene reasons, while 28.2% of the male youth and 28.6% of men cited HIV risk minimization. Religion also plays a role, with 17.9% of male youth and 20.5% of men citing it as a reason for circumcising. Cultural influence is minimal, and other reasons vary across districts.

Table 7 The main reason for circumcision among male youth 15–24 years and men 15 + years
Full size table

Reasons for not getting circumcised

Table 8 summarises the findings. Fear of pain as reported by 36.2% of the male youth 15–24 years was the leading reason for not circumcising, a pattern also observed at the districts except Mubende where the leading reason was fear of getting infected as reported by 24.9% of the male youth. The other reasons frequently reported for not circumcising were being unsure of benefits of circumcision (13.7%), and fear of getting infected as reported by 6.2% of the male youth 15–24 years. District-level variation in reasons for not circumcising exists (Table 8).

Table 8 Reasons for not going for circumcision among the male youth 15–24 years
Full size table

Discussion

Our findings show disparity in knowledge of signs and symptoms of STIs across the population sub-groups; mothers of children aged 0–11 months were most knowledgeable about the signs or symptoms of STIs in women, while youths 15–25 years were least knowledgeable on the same. Similarly, mothers of children 0–11 months and men 15 + years were most knowledgeable about the signs and symptoms of STIs in men while the youth 15–24 years exhibited the least knowledge on this indicator. The mothers of children 0–11 months had the highest coverage in terms of knowing what to do if one has an STI while youth 15–24 years had the least coverage of all the study sub-groups. The high level of knowledge observed among mothers of children aged 0–11 months is likely due to their recent exposure to the healthcare system during antenatal, prenatal, or postnatal care, where they may have received messages and information about STI prevention and control. Similar to our findings on youth, a previous study assessing the knowledge and attitudes of secondary school adolescents regarding STI prevention in Nigeria reported low levels of knowledge about STI symptoms among adolescents, although that study focused on individuals aged 10–24 years [29]. It is worth noting that there were methodological differences in design between this study and ours.

The source of the information is critical because peers and some media sources may provide inaccurate information. For example, during their antenatal, prenatal, or postnatal care, women are offered information of how STIs manifest and how to prevent STIs, which is an important component of the health education messages [30]. Unlike the mothers of children 0–11 months children, most men, and youths are likely to obtain STI information from other sources as observed in a study in Iran where the internet and friends were the common source of information about STIs among men [31]. Among the youth in Africa, the common source of knowledge are usually the media and teachers [32]. These findings present opportunity to learn from the routine health education provided during antenatal care. Integrating health education in routine healthcare such as the outpatient care, school health, and integrated outreaches could improve the situation among the other population sub-groups [33]. The inadequacy of knowledge about STIs observed in this study, particularly among youths, may have an impact on service utilisation. Lack of knowledge may lead to poor STIs health seeking behavior, which has a negative impact on disease prevention [34].

The districts of Kyankwanzi, Nakaseke, Kiboga, and Luwero consistently showed a low coverage of knowledge and awareness about STIs across the four demographic groups studied. The SAs AE (Kalagala SC, Zirobwe SC), AF (Kapeeka SC, Semuto SC, Semuto TC) in Kiboga, and AG (Nakaseke SC, Nakaseke TC Kasangombe SC) in Nakaseke had low STI knowledge coverage compared to the average coverage in the different respondent groups. These findings underline the need for targeted policies, interventions, resources allocation, practices and management strategies to enhance STI knowledge and awareness in low coverage districts and SAs. Further investigating bottlenecks that may have contributed to the observed low level of knowledge in the identified population sub-groups, districts and SAs is needed. Identifying bottlenecks in low indicator coverage helps identify challenges, allows understanding of root causes, offers tailored solutions, optimises resource use, and enhances monitoring thus maximising progress [35]. Examining why some districts and SAs performed exceptionally well, can help draw lessons to the underperforming districts and SAs so that practical strategies for improvement can be applied in the underperforming areas [36]. Given the similarities in context such as culture, location from the center, tribe etc. between our study districts, it is important to consider additional explanatory or analytical studies to better understand why certain districts such as Nakaseke persistently demonstrated low knowledge of STI symptoms and actions to take when one has an STI across virtually all the demographic groups.

Youth (15–24 years) are less aware of what actions they should take if they anticipated having an STI compared to other demographics in this study. A study on HIV care retention among youth in rural South Western Uganda found similar patterns, suggesting a potential gap in comprehensive sexual health education [37]. Several factors contribute to this, including inadequate education at school and at home, fear of judgment or stigma, and communication barriers with healthcare providers [38]. Furthermore, youth access to sexual healthcare is limited by barriers such as cost, transportation, and confidentiality concerns. Additionally, young people tend to underestimate their own STI risks, which can result in delayed treatment or inadequate prevention [39]. Gaps in knowledge among youth have resulted in insufficient access to youth-friendly sexual and reproductive health services in low- and middle-income countries including Uganda, resulting into a high prevalence of STIs.

Men 15 + years (35.2%, 95% CI: 31.3–39.2) have higher tendencies to engage in high-risk sexual intercourse compared to women 15–49 years (11.0%, 95% CI: 8.4–13.6), and the youth 15–24 years (15.7%, 95% CI: 10.4–20.9), a finding consistent with earlier reports in Uganda [40]. The observed disparity in risky sexual behavior among men and women in sub-Saharan Africa results from a blend of social, economic, and individual factors including among others, the pressure to conform to social norms that portray men as having sexual prowess compared to women, economic empowerment, peer influence, biological factors such as testosterone that tend to drive men into higher sexual desire, relationship dynamics, cultural beliefs, and substance use [41]. However, in order to provide appropriate targeted interventions and improve reproductive health outcomes, the district health managers in the study districts ought to understand these drivers.

While only a small proportion (11.0%) of women 15–49 years had sex with more than one sexual partner in the previous year, only 51.4% used a condom during their most recent act of sexual intercourse with a non-marital or non-cohabiting sexual partner. Whereas a high proportion of men 15 + years had multiple sexual relationships or had sex with other non-consensual partners in the previous 12 months, a relatively high proportion (76.7%) of them used a condom in their most recent act of high-risk sexual intercourse. These findings can be explained by the fact that historically, gender norms and masculinities have favored male sexual decisions and stigmatized condom use among women [42]. This has potentially reduced women's ability to make decisions about condom use. Thus, different interventions should be used to improve sexual behavior in men and women. The interventions for men should focus on preventing non-marital or non-cohabiting sexual intercourse, while those for women should focus on empowering them to use or requiring their non-consensual partner(s) to use condoms.

The findings have also revealed that men and youth have insufficient knowledge of STI prevention. Similar findings were observed in previous studies, an issue which may increase both groups’ chances of engaging in riskier sex [43]. We found that 60.2% of youth aged 15–24 years had ever had sexual intercourse and this figure is slightly higher than a figure of 40% reported in an earlier study in Nigeria [29]. These findings put young people particularly at a very high risk of contracting STIs and HIV, as well as having an unwanted or early pregnancy. With high-risk sexual behavior among the youth 15–24 years, only 69.3% believe they are at low or no risk of contracting HIV/AIDS. To change the status quo among the youth, integrated approaches focusing on sex education, condom promotion, STI education and management, and HCT are required. These interventions should be tailored to the communication channels deemed most effective based on the district's communication assessment. Such interventions ought to be contextualized given the variation in coverage among the districts and SAs.

The finding that 60.2% of Ugandan youth (15–24 years old) have had sexual intercourse aligns with previous research, which found that half of Ugandan women and nearly four in 10 men aged 15–19 have ever had sex, with this proportion being even higher among 18–19-year-olds [44]. Besides, 15.7% of youth 15–24 years had sex with more than one sexual partner in the last 12 months with only 26.7% using a condom during such risky sexual encounter. The findings align with previous studies indicating high sexual risk behavior among youth in sub-Saharan Africa [41]. The above findings reveal public health concerns among the youth in the study area characterized by high sexual activity, early sexual debut, and limited access to reproductive health services. These pose significant STI risk and unplanned pregnancies highlighting the need for youth-friendly healthcare, heightened sexual health and education initiatives and community engagement to promote healthy sexual behaviors. Improving sexual behaviour and condom use among the youth requires prioritising Mubende and Kyankwanzi districts. The two districts had high proportion of youth who ever had sex yet they perceive a low risk of HIV, low proportion ever used a condom, and very low proportion used a condom during the last high risk sexual intercourse. Mubende had majority of its SAs had low-coverage SAs in most indicators and Kyankwanzi district had high proportion have sex with more than one sexual partner in the last 12 months. This is more important given that Mubende district has also had the second highest HIV infection rates among the eight districts according to the latest HIV indicator survey, next to Luwero district [45]. On the other hand, a study conducted in two sub-counties within Kyankwanzi district located in SAs I and J in 2016 revealed that adolescents were engaging in sexual activity as early as the ages 14 to 15, with challenges of access to sexual and reproductive health cited as one of the reasons for this occurrence [46]. Thus, targeting the poor-performing SAs in these districts provides avenue for fast-tracking improvements especially in indicators where these districts have performed worst.

The proportion of male young 15–24 years and men 15 + years who had been circumcised was 68.6% and 58.8% respectively. This implies that circumcision rates among young men are higher than in the general population. Proportions of the circumcised male youth 15–24 years and men in the general population in this study are higher than the national averages of 48.7% and 46% respectively, according to the most recent Uganda demographic and health survey [47]. Despite the fact that these proportions among the general population's youth and men are above or close to the 60% required to influence population-level biomedical HIV and STI prevention, the current prevalence of circumcision in the study area remains below Uganda's ministry of health's 2025 target coverage of 80% to provide adequate protection against HIV and other STIs [48]. Furthermore, there are differences between districts, with the male youth circumcision coverage estimates in Kyankwanzi (46.9%) and Nakaseke (39.9%) districts way below the 60% threshold required to trigger population-level biomedical HIV prevention, while Nakasongola district (67.0%) despite exceeding the 60.0% threshold falls short of the average coverage. The coverages among the men in this study fell short of the 60% mark in Nakaseke, Nakasongola, and Kasanda districts, making them high-priority districts for intervention regarding safe male circumcision.

The findings suggest that personal hygiene and HIV risk minimization are the primary drivers for accepting circumcision, with religion also playing a significant role. Cultural influence is relatively minimal, and other reasons are varied. These insights can inform public health strategies and education initiatives promoting circumcision for HIV prevention and improved reproductive health. Accordingly, efforts should be made to raise awareness about safe male circumcision as a supplement to existing behavioral and medical STIs prevention strategies, with a focus on early timing of circumcision prior to sexually active age. Circumcision may be less acceptable to 13.7% of youth 15–24 years who were unsure of the benefits of circumcision and 6.2% of youth 15–24 years who were afraid of getting infected during the circumcision process. Other reasons fronted for not circumcising were not knowing where to get services, lack of services, long distance and lack of trust in the providers. Previous research has reported similar feelings as reasons for not accepting to circumcise [49]. Given that fear of pain was reported as the most common impediment to safe male circumcision uptake, messages promoting safe male circumcision should emphasize that safe male circumcision is performed under anaesthesia and thus painless. The differences in reasons for and against circumcision across districts highlight the need for context/district specific interventions to improve coverage of safe male circumcision in each district.

Strengths of the study

This study focuses on STI knowledge, addressing one of the most under-researched areas in Uganda and other low- and middle-income countries. It examines STI knowledge, sexual behavior, and condom use across various demographic groups, including youth aged 15–24 years, a critical yet often under-researched target group for STI prevention and control. Additionally, the study provides insights into using the LQAS approach in STI prevention, offering decentralized data to support local decision-making.

Conclusion

This research reveals a wide range of coverage across indicators, districts, SAs, and even respondent groups. Mothers of children 0–11 months were more likely to have higher coverage, whereas youth in general had low coverage across the board. While most indicators in the project's catchment area should prioritize youth intervention, other groups require targeted interventions. Variations in indicator coverage across districts and SAs suggest that targeted district and SA-specific interventions may be required to improve local coverage. Districts should conduct local-situation analyses on a regular basis and develop context-specific interventions rather than blanket ones. Districts and SAs that are underperforming should learn from their counterparts that are performing well.

Study limitations

These finding should be interpreted with caution due to the potential presence of reporting bias inherent in self-reported data, which may either overestimate or underestimate the actual prevalence of the situations under investigation. In addition, the questionnaires were interviewer-administered. While dealing with a sensitive topic like STIs and sexual behaviour, self-administration of questionnaires is ideal. Due to the use of interviewer-administered questionnaires in this study, some participants may have withheld information on account of the sensitivity of the topic, potentially leading to underestimation or overestimation of coverage for certain indicators.

Data availability

All data and material for this study has been provided in the article.

Abbreviations

AIDS:

Acquired Immunodeficiency Syndromme

DR:

Decision Rule

HIV:

Human Immunodeficiency Virus

LQAS:

Lot Quality Assurance Sampling

PPS:

Probability Proportionate to Size

SA:

Supervision Area

SC:

Sub-county

TC:

Town Council

WHO:

The World Health Organisation

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Acknowledgements

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Funding

This study was funded by the U.S. Centers for Disease Control and Prevention Kampala Office Cooperative Agreement number:GH002046 as Mildmay Uganda for Mubende Region-18033.

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Authors and Affiliations

  1. Mildmay Uganda, Kampala, Uganda

    Semei Christopher Mukama, Jane Nakawesi, Dedrix Stephenson Bindeeba, Simons Ezajobo, Susan Nakubulwa, Andrew Mugisa, Mary Odiit, Catherine Senyimba, Eve Namitala & Barbara Mukasa

  2. Gudie University Project, P.O. Box 27450, Kampala, Uganda

    Simon Peter Katongole

  3. Liverpool School of Tropical Medicine (LSTM), Department of International Public Health, Kampala, Uganda

    Robert D. D. M. Onzima Anguyo

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  1. Simon Peter Katongole
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Contributions

This study's co-authors all contributed to its conception and design, data collection, analysis, results interpretation and critical review of the manuscript.

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Correspondence to Simon Peter Katongole.

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Ethics approval and consent to participate

Ethical approval was obtained from the Mildmay Uganda Research and Ethics Committee # REC REF 0804–2018 and the Uganda National Council of Science and technology number SS639ES. Participant consent was obtained before enrollment. Before conducting any interviews, we ensured that all participants provided their informed consent to participate in the study. A detailed explanation of the study's objectives and procedures was provided to each participant. Afterward, they signed the informed consent forms. Participants unable to sign the consent form affixed their thumbprint. In cases where participants were under the age of 18, we first obtained consent from their parents or legal guardians, and then secured the participants'own informed consent.

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Katongole, S.P., Mukama, S.C., Nakawesi, J. et al. Evaluating the coverage of sexually transmitted infection prevention and control services in eight districts in Central Uganda: lot quality assurance sampling survey. BMC Infect Dis 25, 659 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12879-025-11013-2

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BMC Infectious Diseases

ISSN: 1471-2334

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