Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia.

BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

HIV, syphilis and sexual-risk behaviours' prevalence among in-and out-of-school adolescent girls and young women in Zambia: A cross-sectional survey study.

BACKGROUND: In Zambia, 3.8% of young women and men aged 15-24 are HIV positive. However, like in most developing nations, HIV prevalence is higher among young women than young men (5.6% versus 1.8%). Despite the recognition of the rights of young people to sexual reproductive health (SRH) information and services, adolescent and young people (AYP) still face challenges in accessing healthcare in public health institutions including access to comprehensive knowledge on HIV/AIDs, HIV testing and contraceptives. The overall objective of the study was to collect baseline HIV, SRH and gender based violence (GBV) data at district level to inform the design of interventions targeting adolescent girls and young women (AGYW) aged 10-24 years in 20 districts of Zambia. METHODS: A cross-sectional, mixed-methods study was conducted in 20 districts of Zambia with the highest incidence of HIV. Data was collected between August and October 2022 with a total response rate of 92% (12,813/13960), constituting 5979 (46.7%) in-school and 6834 (53.3%) out-of-school participants. RESULTS: Overall, Mwinilunga, Chinsali, Chisamba and Chembe districts had the highest number of respondents, while Sinazongwe and Mungwi districts contributed the least. The overall age distribution was such that 12.6% (n = 1617) of those interviewed were aged 10 to 14 years, 35.4% (n = 4536) were aged 15-19 years, and 52.0% (n = 6660) were aged 20-24 years. The overall mean age at first sex among AGYW interviewed was 16.6 years which was broken down as follows: 16.2 years for in-school and 16.8 years for out of school. Overall, most of the respondents had first time sex with either their boyfriend (80.4%) or husband (15.6%), with 2.4% of the in-school participants reporting to have had their sexual debut in marriage compared to 21.0% among out-of-school AGYW. Prevalence of HIV was higher in the out-of-school compared to the in-school participants (5.5% vs 2.0%), Similarly, the prevalence of syphilis was higher in the out-of-school than the in-school participants (4.1% vs 1.5%). CONCLUSION: The study focused on assessing the prevalence and vulnerability of HIV, syphilis, GBV, and SRH services uptake among adolescent girls and young women, and exploring factors affecting girls' stay-in-school and re-engagement. The study found that HIV and syphilis are still significant public health problems among adolescent girls and young women in Zambia, emphasizing the need for increased efforts to prevent and manage these infections.

Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents' sexual and reproductive health needs in rural Zambia.

INTRODUCTION: Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents. METHODS: Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis. RESULTS: We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges. CONCLUSION: Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

The Association of Emotional Support, HIV Stigma, and Home Environment With Disclosure Efficacy and Perceived Disclosure Outcomes in Young People Living With HIV in Zambia: A Cross-Sectional Study.

ABSTRACT: This study examined the association of various forms of social support, attitudes toward living at home, and HIV stigma experiences with HIV self-disclosure efficacy and perceived negative disclosure outcomes. We analyzed cross-sectional data from 120 young people with HIV (YPWH) aged 18-21 years receiving outpatient care in Eastern Province, Zambia. Perceived negative disclosure outcomes and disclosure self-efficacy were measured using an adapted version of the Adolescent HIV Disclosure Cognitions and Affect Scale. Explanatory variables included parental or caregiver support, emotional support, instrumental support, HIV stigma experiences, and attitudes toward living at home. Findings suggest that YPWH's confidence in their ability to self-disclose their HIV status and their assessment of negative outcomes associated with HIV disclosure are influenced by emotional support, experiences of HIV stigma, and the quality of the home environment.

Community health workers: essential in ensuring primary health care for equitable universal health coverage, but more knowledge and action is needed.

Community health workers (CHWs) have helped improve access to quality primary health care (PHC). However, knowledge gaps exist in designing and implementing CHW-engaged models needed to ensure quality people-centered PHC. In this collection, we call for papers which bridge this knowledge gap, to build sustainable, resilient and equitable CHW programs.

Unlocking policy synergies, challenges and contradictions influencing implementation of the Comprehensive Sexuality Education Framework in Zambia: a policy analysis.

BACKGROUND: Comprehensive sexuality education (CSE) has recently become salient, but adolescent sexual reproductive health and rights (ASRHR) challenges are still a global health problem. Studying policies which have implications for CSE implementation is a crucial but neglected issue, especially in low and middle-income countries (LMICs) like Zambia. We analyzed policy synergies, challenges and contradictions influencing implementation of CSE framework in Zambia. METHODS: We conducted a document review and qualitative interviews with key stakeholders from Non-Governmental Organizations, as well as health and education ministries at the National and all (10) provincial headquarters. Our methods allowed us to capture valuable insights into the synergies, challenges and contradictions that exist in promoting CSE framework in Zambia. RESULTS: The study highlighted the synergies between policies that create opportunities for implementation of CSE through the policy window for adoption of sexual reproductive health and rights (SRHR) that opened around the 1990s in Zambia, promotion of inclusive development via education, adoption of an integrated approach in dealing with SRHR problems, and criminalization of gender-based violence (GBV). This analysis also identified the policy challenges and contradictions including restricted delivery of education on contraception in schools; defining childhood: dual legal controversies and implications for children, grey zones on the minimum age to access SRHR services; inadequate disability inclusiveness in SRHR legal frameworks; policy silences/contentious topics: LGBTQI + rights, abortion, and grey zones on the minimum age to access SRHR services. CONCLUSION: While many policies support the implementation of CSE in schools, the existence of policy silences and challenges are among the barriers affecting CSE implementation. Thus, policy reformulation is required to address policy silences and challenges to enhance effective promotion and integration of the CSE framework.

Applying community health systems lenses to identify determinants of access to surgery among mobile & migrant populations with hydrocele in Zambia: A mixed methods assessment.

Hydrocele which is caused by long term lymphatic filariasis infection can be treated through the provision of surgery. Access to surgeries remains low particularly for hard to reach populations. This study applied community health system lenses to identify determinants to the adoption, implementation and integration of hydrocele surgeries among migrants &mobile populations in Luangwa District, Zambia. A concurrent mixed methods design consisting of cross-sectional survey with hydrocele patients (n = 438) and in-depth interviews with different community actors (n = 38) was conducted in October 2021. Data analysis was based on the relational and programmatic lenses of Community Health Systems. Under the Programmatic lens, insufficient resources resulted in most health facilities being incapable of providing the minimum package of care for lymphatic filariasis. The absence of cross border collaborative structures limits the continuity of care for patients moving across the three countries. Other programmatic barriers include language barriers, inappropriate appointment systems, direct and indirect costs. In the relational lens, despite the key role that community leaders play their engagement in service delivery was low. Community actors including patients were rarely included in planning, implementation or evaluation of hydrocele services. Some patients utilized their power within to act as champions for the surgery but local groups such as fishing associations remained underutilized. Community health systems provide a potential avenue through which access amongst mobile and migrant populations can be enhanced through strategies such engagement of patient groups, knowledge sharing across borders and use of community monitoring initiatives.

The role of principled engagement in public health policymaking: the case of Zambia's prolonged efforts to develop a comprehensive tobacco control policy.

BACKGROUND: The Framework Convention on Tobacco Control (FCTC) requires countries to develop and implement multi-sectoral tobacco control strategies, including policies and legislation. Zambia, potentially faced by a rising problem of tobacco smoking, signed the FCTC in 2008 but has been unable to enact a tobacco policy for over a decade. OBJECTIVE: This study explores the role of 'principled engagement', a key element of the theoretical framework for collaborative governance, in Zambia's delayed success to develop a comprehensive tobacco control policy. METHODS: This was a qualitative case study of key stakeholders in the collaborative process of trying to develop a tobacco policy in Zambia. Participan-ts were sampled from across various sectors, including government departments and civil society, comprising anti-tobacco activists and researchers. A total of 27 key informant interviews were undertaken. We supplemented the interview data with a document review of relevant policies and legislation. Data were analysed using thematic analysis. RESULTS: Several factors hindered efforts to attain principled engagement, including the adverse legal and socioeconomic environment in which the collaborative regime evolves; poor planning of meetings and frequent changes in tobacco focal point persons; lack of active and meaningful participation; and communication challenges among the key stakeholders. These collaborative dynamics, coupled with the opposition to tobacco control efforts from within some government departments, revealed the inadequacy of the current collaborative governance regime to facilitate enactment of a comprehensive tobacco control policy in Zambia. CONCLUSION: Efforts to develop a comprehensive tobacco control policy in Zambia will require addressing challenges such as disagreements, communication, and leadership at engagement level across interested sectors. We further argue that principled engagement has a greater role to play in unlocking these efforts and should therefore be embraced by those entrusted to lead the process to develop tobacco policy in Zambia.

Exploring communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia.

BACKGROUND: The World Health Organization has promoted a shift towards the test-and-treat-all strategy to accelerate the elimination of HIV/AIDS. Zambia was one of the early African countries to adopt this strategy as the policy change was officially announced on national television by the republican president on 15th August 2017. This study explored the communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia. METHODS: A qualitative case study design was employed with a purposeful sample of policy makers, international partners, National AIDS Council representatives, health facility managers, and frontline health providers in selected tertiary, secondary and primary health facilities in the Lusaka District, Zambia. Thematic data analysis was performed using NVivo 12 Pro software. RESULTS: In total, 22 key informant interviews and 3 focus group discussions were conducted. The government relied on formal and informal channels to communicate the test-and-treat-all policy change to health providers. Whilst HIV policy changes were reflected in the National HIV/AIDS Strategic Framework, there was little awareness of this policy by the frontline providers. The use of informal communication channels such as verbal and text instructions affected health providers' implementation of the test-and-treat-all. Electronic and print media were ineffective in communicating the test-and-treat-all policy change to some sections of the public. Top-down stakeholder engagement, limited health worker training, and poor financing negatively affected the implementation of the test-and-treat-all policy change. Acceptability of the test-and-treat-all policy change was shaped by positive provider perceptions of its benefits, limited sense of policy ownership, and resistance by the non-treatment-ready patients. Furthermore, unintended consequences of the test-and-treat-all policy change on human resources for health and facility infrastructure were reported. CONCLUSION: Effective test-and-treat-all policy change communication is vital for successful policy implementation as it enhances interpretation and adoption among health providers and patients. There is a need to enhance collaboration among policy makers, implementers and the public to develop and apply communication strategies that facilitate the adoption of the test-and-treat-all policy changes to sustain gains in the fight against HIV/AIDS.

Gender integration and female participation in scientific and health research in Zambia: a descriptive cross-sectional study protocol.

INTRODUCTION: Despite the Zambian government making progress on prioritising gender mainstreaming, female participation in science, technology and innovation in academia, research and development is still low. This study aims to determine the integration of gender dimensions and the factors that influence female participation in science and health research in Zambia. METHODS AND ANALYSIS: We propose a descriptive cross-sectional study design employing in-depth interviews (IDIs) and survey as data collection techniques. Twenty schools offering science-based programmes will be purposively selected from University of Zambia (UNZA), Copperbelt University, Mulungushi University and Kwame Nkrumah University. In addition, two research institutions, Tropical Disease Research Centre and Mount Makulu Agricultural Research Station, will be included. Survey respondents will include a random sample of 1389 academic and research staff from the selected schools. A total of 30 IDIs will be conducted with staff and heads of selected schools and research institutions. Data collection will be conducted over a 12-month period. Before commencement of data collection, in-depth literature search and record review on gender dimensions in science and health research will be conducted to gain insight into the subject matter and inform research instrument design. Survey data and IDIs will be collected using a structured paper-based questionnaire and semistructured interview guide, respectively. Descriptive statistics will be computed to summarise respondents' characteristics. Bivariate analysis (χ2 test and independent t-test) and multivariate regression analysis will be conducted to test the association and identify factors influencing female participation in science and health research (adjusted ORs, p<0.05). An inductive approach will be used to analyse qualitative data using NVivo. Survey and IDI will be corroborated. ETHICS AND DISSEMINATION: This study involves human participants and was approved by UNZA Biomedical Research Ethics Committee (UNZABREC; UNZA BREC 1674-2022). Participants gave informed consent to participate in the study before taking part. Study findings will be disseminated through a written report, stakeholder meetings and publication in a peer-reviewed international journal.

Experiences of teachers and community-based health workers in addressing adolescents' sexual reproductive health and rights problems in rural health systems: a case of the RISE project in Zambia.

BACKGROUND: Adolescents in low-and-middle-income countries like Zambia face a high burden of sexual, reproductive, health and rights problems including coerced sex, teenage pregnancies, and early marriages. The Zambia government through Ministry of Education has integrated comprehensive sexuality education (CSE) in the education and school system to contribute towards addressing Adolescents sexual, reproductive, health and rights (ASRHR) problems. This paper sought to explore teachers and community based health workers (CBHWs)' experiences in addressing ASRHR problems in in rural health systems in Zambia. METHODOLOGY: The study was conducted under Research Initiative to Support the Empowerment of Girls (RISE) community randomized trial that aims to measure the effectiveness of economic and community interventions in reducing early marriages, teenage pregnancies, and school dropout in Zambia. We conducted qualitative 21 in-depth interviews with teachers and CBHWs involved in the implementation of CSE in communities. Thematic analysis was used to analyse teachers and CBHWs´ roles, challenges, and opportunities in promoting ASRHR services. RESULTS: The study identified teachers and CBHWs roles, and challenges experienced in promoting ASRHR and suggested strategies to enhance delivery of the intervention. The role of teachers and CBHWs in addressing ASRHR problems included mobilizing and sensitizing the community for meetings, providing SRHR counseling services to both adolescents and guardians, and strengthening referral to SRHR services if needed. The challenges experienced included stigmatization associated with difficult experiences such as sexual abuse and pregnancy, shyness among girls to participate when discussing SRHR in the presence of the boys and myths about contraception. The suggested strategies for addressing the challenges included creating safe spaces for adolescents to discuss SRHR issues and engaging adolescents in coming up with the solution. CONCLUSION: This study provides significant insight on the important roles that teachers CBHWs can play in addressing adolescents SRHR related problems. Overall, the study emphasizes the need to fully engage adolescents in addressing adolescents SRHR problems.

Comprehensive sexuality education programmes are often not implemented properly because facilitators are not adequately prepared, and the community usually resist such programs. Similarly, in Zambia, the teachers and CBHWs implementing sexual and reproductive health activities often felt uncomfortable discussing sensitive sexuality topics with adolescents. This study was conducted within a bigger research project exploring whether teachers and community-based health workers together can effectively deliver sexual and reproductive health information at school and community levels. Discussions on the delivery of ASRHR services were held with teachers and CBHWs to identify their roles, and challenges that they experienced, and find solutions to problems. The interviews showed that the teachers and CBHWs provided sexual reproductive health and rights (SRHR) counselling to adolescents and parents. They were also involved in mobilising communities to attend SRHR meetings, sensitise, and refer them to SRHR services. However, teachers and CBHWs encountered several challenges. These include late reporting and hiding of sexual abuse cases, myths about contraceptives, and stigmatisation of girls with history of sexual abuse, and pregnancy. Further, girls felt shy to participate in SRHR discussions due to customary norms and values regarding marriage. More community engagement opportunities are needed to break the barriers of communication, and shift cultural norms to help enhance adolescent uptake of SRHR services in order to prevent pregnancy and other related challenges.

Assessment of contextual factors shaping delivery and uptake of isoniazid preventive therapy among people living with HIV in Dar es salaam, Tanzania.

BACKGROUND: Tuberculosis has remained a leading cause of death among people living with HIV (PLHIV) globally. Isoniazid preventive therapy (IPT) is the recommended strategy by the World Health Organization to prevent TB disease and related deaths among PLHIV. However, delivery and uptake of IPT has remained suboptimal particularly in countries where HIV and TB are endemic such as Tanzania. This study sought to assess contextual factors that shape delivery and uptake of IPT in Dar es Salaam region, Tanzania. METHODOLOGY: We employed a qualitative case study design comprising of in-depth interviews with people living with HIV (n = 17), as well as key informant interviews with clinicians (n = 7) and health administrators (n = 7). We used thematic data analysis approach and reporting of the results was guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Characteristics of IPT such as aligning the therapy to individual patient schedules and its relatively low cost facilitated its delivery and uptake. On the contrary, perceived adverse side effects negatively affected the delivery and uptake of IPT. Characteristics of individuals delivering the therapy including their knowledge, good attitudes, and commitment to meeting set targets facilitated the delivery and uptake of IPT. The process of IPT delivery comprised collective planning and collaboration among various facilities which facilitated its delivery and uptake. Organisational characteristics including communication among units and supportive leadership facilitated the delivery and uptake of IPT. External system factors including HIV stigma, negative cultural and religious values, limited funding as well as shortage of skilled healthcare workers presented as barriers to the delivery and uptake of IPT. CONCLUSION: The factors influencing the delivery and uptake of IPT among people living with HIV are multifaceted and exist at different levels of the health system. Therefore, it is imperative that IPT program implementers and policy makers adopt multilevel approaches that address the identified barriers and leverage the facilitators in delivery and uptake of IPT at both community and health system levels.

Perspectives on the COVID-19 vaccine uptake: a qualitative study of community members and health workers in Zambia.

OBJECTIVE: Since introduction of the programme in April 2021, COVID-19 vaccine uptake has been low at less than 20%. This study explored community members' and health workers' perspectives on the COVID-19 vaccine uptake and its influencing factors in Zambia. STUDY DESIGN: A qualitative study employing focus group discussions (FGDs) and in-depth interviews (IDIs). STUDY SETTING: Sixteen primary healthcare facilities selected from Lusaka, Copperbelt, Central and Southern provinces. PARTICIPANTS: A total of 32 FGDs comprising local community members and 30 IDIs including health workers, traditional, religious and civic leaders (n=272). FGDs were separated based on age (youth and adults), sex (male and female) and place of residence (urban and rural). RESULTS: Both FGD and IDI participants agreed that vaccine uptake was low. Limited knowledge, access to information, myths and misconceptions, negative attitude, low-risk perception and supply in remote areas affected vaccine uptake. Overall, FGD participants expressed limited knowledge about the COVID-19 vaccine compared with health workers. Further, FGD participants from urban sites were more aware about the vaccine than those from rural areas. Health workers perceived the vaccine to be beneficial; the benefits included prevention of infection and limiting the severity of the disease. Moreover, FGD participants from urban sites expressed a negative attitude towards the vaccine. They believed the vaccine conferred no benefits. By contrast, participants from rural communities had mixed views; they needed more information about the vaccine benefits. Participants' attitude seems to have been influenced by personal or family experience with the COVID-19 disease or vaccination; those who had experienced the disease had a more positive attitude. In contrast, most young people believed they were not at risk of the COVID-19 disease. Misinformation from social media influenced their attitude. CONCLUSION: These results provide starting points for future policies and interventions for increasing COVID-19 vaccine uptake.

Factors influencing the integration of comprehensive sexuality education into educational systems in low- and middle-income countries: a systematic review.

BACKGROUND: Comprehensive sexuality education (CSE) plays a critical role in promoting youth and adolescent's sexual and reproductive health and wellbeing. However, little is known about the enablers and barriers affecting the integration of CSE into educational programmes. The aim of this review is to explore positive and negative factors influencing the integration of CSE into national curricula and educational systems in low- and middle-income countries. METHODS: We conducted a systematic literature review (January 2010 to August 2022). The results accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards for systematic reviews. Data were retrieved from the PubMed, Cochrane, Google Scholar, and Web of Hinari databases. The search yielded 442 publications, of which 34 met the inclusion criteria for full-text screening. The review is guided by an established conceptual framework that incorporates the integration of health innovations into health systems. Data were analysed using a thematic synthesis approach. RESULTS: The magnitude of the problem is evidenced by sexual and reproductive health challenges such as high teenage pregnancies, early marriages, and sexually transmitted infections. Awareness of these challenges can facilitate the development of interventions and the implementation and integration of CSE. Reported aspects of the interventions include core CSE content, delivery methods, training materials and resources, and various teacher-training factors. Reasons for adoption include perceived benefits of CSE, experiences and characteristics of both teachers and learners, and religious, social and cultural factors. Broad system characteristics include strengthening links between schools and health facilities, school and community-based collaboration, coordination of CSE implementation, and the monitoring and evaluation of CSE. Ultimately, the availability of resources, national policies and laws, international agendas, and political commitment will impact upon the extent and level of integration. CONCLUSION: Social, economic, cultural, political, legal, and financial contextual factors influence the implementation and integration of CSE into national curricula and educational systems. Stakeholder collaboration and involvement in the design and appropriateness of interventions is critical.

Adolescents and young people, especially those from low and middle-income countries (LMICs) face sexual and reproductive health (SRH) challenges. This review identifies factors that impact upon the integration of comprehensive sexuality education (CSE) into national curricula and educational systems in LMICs. A total of 442 original articles, published between 2010 and August 2022, were sourced from various databases. Thirty-four articles met the inclusion criteria. Social, economic, cultural, political, legal and financial factors are major enablers and barriers affecting the integration of CSE into educational systems in LMICs. Authorities in many countries are motivated to develop CSE interventions to help reduce SRH issues such as teenage pregnancies, early marriages, HIV/AIDS, and sexually transmitted infections (Yakubu and Salisu in Reprod Health 15:15, 2018;Herat in Reprod Health 15:1­4, 2018;). The rollout of CSE interventions is highly dependent on the availability of training resources, manuals, skilled teachers, and financing. In addition, the perception of teachers, students, politicians, and the community, influences the integration of interventions. This review shows that the involvement of key players in teaching is vital for successful implementation, as is building working relationships between teachers and community actors. Such collaborations enable the integrated delivery of SRH services. Insufficient monitoring and evaluation systems affects the quality of the implementation and therefore the success of CSE. We believe that community involvement in the development, implementation, monitoring, and evaluation of CSE is a major enabler for successful implementation and integration. Recognising and acknowledging the importance of political, social, legal and financial factors is critical for sustainable CSE integration.

Integration of systematic screening for tuberculosis in outpatient departments of urban primary healthcare facilities in Zambia: a case study of Kitwe district.

BACKGROUND: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia. METHODS: This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun's Integration framework. RESULTS: The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic. CONCLUSION: Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.

Effects of economic support, comprehensive sexuality education and community dialogue on sexual behaviour: Findings from a cluster-RCT among adolescent girls in rural Zambia.

Adolescent girls in Sub-Saharan Africa are at high risk of poor sexual and reproductive health outcomes. We present findings from a cluster-randomised trial in rural Zambia on the effects of economic support, comprehensive sexuality education (CSE) and community dialogue on sexual activity, contraceptive use and beliefs among adolescent girls. We recruited 157 schools in 2016, and all girls in grade 7 were invited to participate. Schools were randomised to either economic support, combined economic support, CSE and community dialogue, or control. Economic support consisted of unconditional cash transfers to girls and their guardians, and payment of school fees for girls continuing to grades eight and nine. CSE and community dialogue meetings focused on practices around girls' fertility, marriage and education. The interventions lasted two years from 2016 to 2018, with follow-up for another two years. The effects on outcomes were measured in 2018 and 2019 and compared using generalised estimating equations. We found that economic support lowered sexual activity (risk ratio (RR) 0.70; 95% C.I. 0.54 to 0.91), with a small added benefit of CSE and community dialogue. Economic support and the additional CSE and community dialogue were effective in lowering unprotected sexual activity (RR 0.53 for combined support vs. control; 95% C.I. 0.37 to 0.75). There was no evidence of intervention effects on contraceptive use among those ever sexually active, but the addition of CSE and community dialogue improved contraceptive use among those recently sexually active (RR 1.26; 95% C.I. 1.06 to 1.50) and knowledge regarding contraceptives (RR 1.18; 95% C.I. 1.01 to 1.38) compared to economic support alone. Perceived community support regarding contraceptives was lower in both intervention arms compared to the control. These findings indicate that economic support in combination with CSE and community dialogue can improve the sexual and reproductive health of adolescent girls.

Combining photo-elicitation and discourse analysis to examine adolescents' sexuality in rural Zambia.

INTRODUCTION: This article aimed to analyse constructions of adolescents' sexualities and sexual health and the consequences of these discourses for adolescents' exercise of their sexual reproductive health and rights (SRHR) in rural Zambia. METHODS: Interpretative repertoires, which is rooted in discursive psychology was used to analyse data from photo-elicitations interviews and focus group discussions. Our participants included 25 adolescents who participated in a SRHR intervention that aimed to reduce adolescents' pregnancies and early marriages. RESULTS: We identified three interpretative repertories: 1) sex is for mature people in which adolescents positioned themselves as 'immature, and young to engage in sex; 2) gendered respectful behaviours in which what was considered disrespectful (and respectful) behaviour in relation to sexuality were strongly influenced by gender, and more clearly defined for girls than it was for boys. Sexuality was not only about individual choices but about being respectful to parents; and 3) acquiring and using knowledge about sexuality in which adolescents conflicted between having and applying SRHR knowledge. CONCLUSION: These repertories offer an important context that shape how adolescents negotiate, adopt and resist SRHR interventions. Future interventions that target adolescents' SRHR must aim to address the sexual scripts that serve to erect barriers against positive sexual behaviours, including access to SRHR services that promote safer sex.

Facilitators and barriers to implementation of integrated community case management of childhood illness: a qualitative case study of Kapiri Mposhi District.

BACKGROUND: Zambia adopted the Integrated Community Case Management (ICCM) of childhood illness strategy in May 2010, targeting populations in rural communities and hard-to-reach areas. However, evidence suggests that ICCM implementation in local health systems has been suboptimal. This study sought to explore facilitators and barriers to implementation of ICCM in the health system in Kapiri Mposhi District, Zambia. METHODS: Data were gathered through 19 key informant interviews with district health managers, ICCM supervisors, health facility managers, and district health co-operating partners. The study was conducted in Kapiri Mposhi district, Zambia. Interviews were translated and transcribed verbatim. Data were were analyzed using thematic analysis in NVivo 11(QSR International). RESULTS: Facilitators to implementation of ICCM consisted of community involvement and support for the program, active community case detection and timeliness of health services, the program was not considered a significant shift from other community-based health interventions, district leadership and ownership of the program, availability of national and district-level policies supporting ICCM and engagement of district co-operating partners. Program incompatibility with some socio-cultural and religious cotexts, stock-out of prerequisite drugs and supplies, staff reshuffle and redeployment, inadequate supervision of health facilities, and nonpayment of community health worker incentives inhibited implementation of ICCM. CONCLUSION: The study findings highlight key faciliators and barriers that should be considered by policy-makers, district health managers, ICCM supervisors, health facility managers, and co-operating partners, in designing context-specific strategies, to ensure successful implementation of ICCM in local health systems.

Sociodemographic factors associated with daily tobacco smoking and binge drinking among Zambians: evidence from the 2017 STEPS survey.

BACKGROUND: The burden of disease attributable to tobacco smoking and harmful alcohol consumption poses a major threat to sustainable development in most low- and middle-income countries. However, evidence on tobacco use and harmful alcohol consumption to inform context-specific interventions addressing these harmful social behaviours is limited in the African context. This study aimed to determine the sociodemographic factors associated with daily tobacco smoking and binge drinking in Zambia. METHODS: The study stems from nationwide population-based representative survey data collected using the World Health Organization's STEPwise approach for non-communicable disease risk factor surveillance in 2017 among 18-69-year-old Zambians. The main outcomes were daily tobacco smoking and binge drinking, and the demographic and socioeconomic variables included sex, marital status, age, residence, level of education and occupation. Prevalence ratios (PR) were calculated using log-binomial regression analysis. RESULTS: Overall, 4302 individuals (weighted percentage 49.0% men and 51.0% women) participated in the survey. The prevalence of daily tobacco smoking was 9.0%, and 11.6% of participants engaged in binge drinking, both of which were higher among men than women (17.1% vs. 1.3% and 18.6% vs. 5.3%, respectively). The adjusted prevalence of daily tobacco smoking was 14.3 (95% CI: 9.74-21.01) times higher in men than women, and 1.44 (95% CI 1.03-1.99) times higher in the > 45-year-old group compared to the 18-29-year-old group. Significant positive associations with daily tobacco smoking were found among those with no education 2.70 (95% CI 1.79- 4.07) or primary education 1.86 (95% CI 1.22-2.83) compared to those with senior secondary or tertiary education. The adjusted prevalence of daily tobacco smoking was 0.37 times lower (95% CI 0.16-0.86) among students and homemakers compared to employed participants. The adjusted prevalence of binge drinking was 3.67 times higher (95% CI 2.83-4.76) in men than in women. Significantly lower adjusted prevalences of binge drinking were found in rural residents 0.59 (95% CI: 0.46-0.77) compared to urban residents and in students/homemakers 0.58 (95% CI: 0.35-0.94) compared to employed participants. CONCLUSION: This study shows huge differences between men and women regarding tobacco smoking and binge drinking in Zambia. A high occurrence of tobacco smoking was observed among men, older members of society and those with lower levels of education, while binge drinking was more common in men and in those living in urban areas. There is a need to reshape and refine preventive and control interventions for tobacco smoking and binge drinking to target the most at-risk groups in the country.

Application of community dialogue approach to prevent adolescent pregnancy, early marriage and school dropout in Zambia: a case study.

BACKGROUND: Adolescent pregnancy carries both health and economic risks for the pregnant girl and resulting baby, and it is common in Zambia. Providing alternative methods of preventing early pregnancy than abstinence is regarded as culturally and religiously unacceptable in most parts of the country. The community dialogue approach is being tested to address norms and beliefs around early pregnancy, marriage and school dropout, and is based on Paulo Freire's transformative communication approach. The objective of this paper was to understand parents' perspectives on the application of the community dialogue approach in addressing adolescents' early pregnancy and school dropout in a cluster randomized controlled trial in rural Zambia. METHODS/DESIGN: This was a case study design. We nested the study in the community dialogue intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Dialogue meetings were held and economic support was provided for a period of 27 months from September 2016 until November 2018. We held focus group discussions in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. All the discussions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. RESULTS: The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators' interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health (SRH) topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their SRH values and subsequently made them feel able to communicate about SRH issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children. CONCLUSION: The study indicated that the community dialogue was appreciated by the parents and helped in addressing cultural barriers to discussing SRH issues between generations.