Health worker perceptions of stigma towards Zambian adolescent girls and young women: a qualitative study.

BACKGROUND: The high prevalence of HIV among adolescent girls and young women aged 15-24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers' perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia. METHODS: We conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed. RESULTS: Health workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics. CONCLUSIONS: These findings demonstrate the overlap in health workers' clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women.

Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia.

CONTEXT: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS: We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION: These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.

"Burnt by the scorching sun": climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-affected communities of Zambia.

BACKGROUND: Climate-induced disruptions like drought can destabilize household and community livelihoods, particularly in low- and middle-income countries. This qualitative study explores the impact of severe and prolonged droughts on gendered livelihood transitions, women's social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces. METHODS: In September 2020, in-depth interviews (n = 20) and focus group discussions (n = 16) with 165 adult women and men in five drought-affected districts, as well as key informant interviews (n = 16) with civic leaders and healthcare providers, were conducted. A team-based thematic analysis approach, guided by the Framework Method, was used to code transcript text segments, facilitating identification and interpretation of salient thematic patterns. RESULTS: Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women's breadwinning and caregiving responsibilities increased, especially in households where women's partners out-migrated in search of employment prospects. As household incomes declined, women and girls' vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or would resort to purchasing health commodities, including family planning, from private retail pharmacies when unavailable from government facilities. Most participants described changes in fertility intentions motivated by drought: women, in particular, expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient. CONCLUSIONS: Drought highlighted persistent and unaddressed vulnerabilities in women, increasing demand for health services while shrinking household resources to access those services. Policy solutions are proposed to mitigate drought-induced challenges meaningfully and sustainably, and foster climate resilience.

Quality of care and HIV service utilization among key populations in Zambia: a qualitative comparative analysis among female sex workers, men who have sex with men and people who use drugs.

HIV epidemic control requires improving access and uptake of HIV services by key populations (KPs). In Zambia, the behaviors of female sex workers (FSWs), men who have sex with men (MSM), and people of who use drugs (PWUD) are criminalized, and little information exists about their HIV/STI service use. Using a quality of care (QOC) framework, we compared barriers to and opportunities for HIV/STI service access and uptake among the three KPs. We conducted in-depth interviews and focus group discussions with 314 KP members between July 2013 and September 2015 in eight districts. Poorer QOC was received at public health facilities compared to private, NGOs and traditional healers. Stigma and discrimination, confidentiality, and legal prosecution were barriers to service use and more salient among MSM than FSWs and PWUD. Invasive facility policies were barriers and more prominent among FSWs than MSM and PWUD. Service unavailability was of equally high salience among MSM and PWUD than FSWs. Comfort in the clinic and perceived treatment effectiveness were facilitators for all three KPs. The health care experiences of KPs are not monolithic; HIV/STI service improvement strategies should address the concerns and be tailored to the needs of each key population.

Motivations for entering and remaining in volunteer service: findings from a mixed-method survey among HIV caregivers in Zambia.

BACKGROUND: A high burden of HIV in many sub-Saharan African countries has triggered renewed interest in volunteer-based community health programmes as a way to support treatment roll-out and to deliver services to children orphaned due to HIV. This study was undertaken as an evaluation of a USAID project implemented by a consortium of 7 NGOs operating in 52 Zambian districts. We aimed to examine motivations for becoming volunteer caregivers, experiences in service and commitment to continue volunteering in the future. METHODS: A mixed-method survey approach was adopted incorporating close- and open-ended questions. District selection (3 of 52) was purposive, based on representation of urban, peri-urban and rural volunteers from a mix of the consortium's NGO affiliates. Individual volunteer recruitment was achieved via group information sessions and opportunistic sampling was used to reach a quota (~300) per study district. All participants provided written informed consent. RESULTS: A total of 758 eligible caregivers were surveyed. Through parallel analyses of different data types and cross-over mixed analyses, we found shifting patterns in motivations across question type, question topic and question timing. In relation to motivations for entering service, responses to both open- and close-ended questions highlighted the importance of value-oriented functions and higher order social aspirations such as "helping society" or "humanity". However, 70% of participants also agreed to at least one close-ended economic motivation statement and nearly a quarter (23%) agreed to all four. Illustrating economic need, as well as economic motivation, over half (53%) the study respondents agreed that they had become a volunteer because they needed help from the project. Volunteers with lower and mid-level standard-of-living scores were significantly more likely to agree with economic motivation statements. CONCLUSIONS: Reliance by national and international health programmes on volunteer workforces is rooted in the assumption that volunteers are less costly and thus more sustainable than maintaining a professional cadre of community health workers. Understanding individuals' motivations for entering and remaining in volunteer service is therefore critical for programme planners and policy makers. This study demonstrated that volunteers had complex motivations for entering and continuing service, including "helping" and other pro-social values, but also manifest expectations of and need for material support. These findings contribute to evidence in support of various reforms needed to strengthen the viability and sustainability of volunteer-dependent services including the need to acknowledge and plan for the economic vulnerability of so-called volunteer recruits.

"I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia.

ABSTRACT: Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.

Intersections of financial agency, gender dynamics, and HIV risk: A qualitative study with adolescent girls and young women in Zambia.

Objectives: Recent research demonstrates that economic interventions may positively effect HIV risk among adolescent girls and young women (AGYW) in sub-Saharan Africa. Some evidence reveals potential associations between financial decision-making and bargaining power in sexual relationships. However, this evidence is mixed, nuanced, and limited. This paper explores how AGYW in Zambia understand financial agency and its effect on intimate relationships. Methods: In-depth qualitative interviews were conducted with 30 females aged 15-24 years residing in Kalingalinga, a low income, high-density residential area in Lusaka. Data were analysed using thematic content analysis. Results: Participants spoke of the ability to earn and spend money as reality for some and aspirational for many others, intrinsic to cultural and religious caveats influencing perceptions of agency for women. The transfer of financial independence to sexual agency within relationships was viewed as a mechanism for HIV risk reduction; however, male sexual privilege was an obstacle irrespective of financial decision-making. Conclusions: Programmes aiming to enhance financial agency for AGYW have the potential to reduce HIV sexual risk. Yet, to be most effective, integration with gender-transformative programmes is needed to address norms of male dominance that keep AGYW in positions of vulnerability.

Multisectoral, Combination HIV Prevention for Adolescent Girls and Young Women: A Qualitative Study of the DREAMS Implementation Trajectory in Zambia.

OBJECTIVE: To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership's implementation. METHODS: In September-October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance. RESULTS: Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. To address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion. CONCLUSIONS: Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors.

Family Support for Adolescent Girls and Young Women Living With HIV in Zambia: Benefits, Challenges, and Recommendations for Intervention Development.

ABSTRACT: Lack of family involvement is barrier to antiretroviral therapy adherence among adolescent girls and young women (AGYW). This study assessed family support for AGYW's engagement along the HIV care continuum to inform the design of a family-focused intervention in Lusaka, Zambia. We conducted 16 in-depth interviews and four focus group discussions with 40 AGYW living with HIV. Three strategies were identified to strengthen family support. First, emotional and instrumental support are highly valued by AGYW and should be further developed or reinforced. Second, AGYW wanted more informational support and open discussion of HIV from family, and an intervention should aim to enhance these types of support. Third, existing appraisal support reinforced anticipated stigma among AGYW and discouraged disclosure, yet participants wished for more interactions with peers living with HIV. Appraisal support should therefore be reframed to help AGYW decide to whom they should disclose and how to do so safely.

Perspectives of Adolescent Girls and Young Women on Optimizing Youth-Friendly HIV and Sexual and Reproductive Health Care in Zambia.

Youth-friendly health care delivery models are needed to address the complex health care needs of adolescent girls and young women (AGYW). The aim of this study is to explore the lived experiences of AGYW seeking comprehensive HIV and sexual and reproductive health (SRH) care and to elicit their preferences for integrated health care services. We conducted in-depth interviews and focus group discussions in Lusaka, Zambia among 69 AGYW aged 10-20 who were HIV-negative or of unknown status and 40 AGYW aged 16-24 living with HIV. The data were coded through deductive and inductive processes and analyzed thematically using modified World Health Organization (WHO) dimensions of quality for youth-friendly services. AGYW expressed preference for one-stop clinics with integrated services that could provide HIV services along with other services such as pregnancy testing and family planning. AGYW also wanted information on staying healthy and approaches to prevent disease which could be delivered in the community setting such as youth clubs. An integrated clinic should address important attributes to AGYW including short wait time, flexible opening hours, assurance of confidentiality and positive staff attitudes. Youth-friendly, integrated care delivery models that incorporate AGYW preferences may foster linkages to care and improve outcomes among vulnerable AGYW.

High rates of sexual violence by both intimate and non-intimate partners experienced by adolescent girls and young women in Kenya and Zambia: Findings around violence and other negative health outcomes.

BACKGROUND: While links between intimate-partner violence (IPV) and HIV risk have been established, less is known about violence perpetrated by people other than intimate partners. In addition, much of the research on IPV has been conducted with adults, while relatively little is known about violence experienced by adolescent girls and young women (AGYW). We examined experiences of sexual violence and associated sexual and mental health among AGYW in Kenya and Zambia. METHODS: Using cross-sectional surveys with women aged 15-24 years, we assessed experience of partner sexual violence among respondents who reported a boyfriend/husband in the last 12 months (Kenya N = 597; Zambia N = 426) and non-partner sexual violence among all respondents (Kenya N = 1778; Zambia N = 1915). We conducted logistic regression analyses to examine experiences of sexual violence and health outcomes. RESULTS: Sexual violence from intimate partners over the last year was reported by 19.1 percent of AGYW respondents in Kenya and 22.2 percent in Zambia; sexual violence from non-partners was reported by 21.4 percent in Kenya and 16.9 percent in Zambia. Experience of sexual violence was associated with negative health outcomes. Violence from non-partners was associated with increased odds of STI symptoms and increased levels of anxiety and depression. Results were similar for violence from partners, although only significant in Kenya. While sexual violence from a non-partner was associated with increased HIV risk perception, it was not associated when the violence was experienced from an intimate partner. CONCLUSIONS: AGYW reported high levels of sexual violence from both intimate partners and non-partners. These experiences were associated with negative health outcomes, though there were some differences by country context. Strengthening sexual violence prevention programs, increasing sexual violence screening, and expanding the provision of post-violence care are needed to reduce intimate and non-partner violence and the effects of violence on AGYW.

Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia.

Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.

Behavior change pathways to voluntary medical male circumcision: narrative interviews with circumcision clients in Zambia.

As an HIV prevention strategy, the scale-up of voluntary medical male circumcision (VMMC) is underway in 14 countries in Africa. For prevention impact, these countries must perform millions of circumcisions in adolescent and adult men before 2015. Although acceptability of VMMC in the region is well documented and service delivery efforts have proven successful, countries remain behind in meeting circumcision targets. A better understanding of men's VMMC-seeking behaviors and experiences is needed to improve communication and interventions to accelerate uptake. To this end, we conducted semi-structured interviews with 40 clients waiting for surgical circumcision at clinics in Zambia. Based on Stages of Change behavioral theory, men were asked to recount how they learned about adult circumcision, why they decided it was right for them, what they feared most, how they overcame their fears, and the steps they took to make it to the clinic that day. Thematic analysis across all cases allowed us to identify key behavior change triggers while within-case analysis elucidated variants of one predominant behavior change pattern. Major stages included: awareness and critical belief adjustment, norming pressures and personalization of advantages, a period of fear management and finally VMMC-seeking. Qualitative comparative analysis of ever-married and never-married men revealed important similarities and differences between the two groups. Unprompted, 17 of the men described one to four failed prior attempts to become circumcised. Experienced more frequently by older men, failed VMMC attempts were often due to service-side barriers. Findings highlight intervention opportunities to increase VMMC uptake. Reaching uncircumcised men via close male friends and female sex partners and tailoring messages to stage-specific concerns and needs would help accelerate men's movement through the behavior change process. Expanding service access is also needed to meet current demand. Improving clinic efficiencies and introducing time-saving procedures and advance scheduling options should be considered.

Female sex workers, male circumcision and HIV: a qualitative study of their understanding, experience, and HIV risk in Zambia.

Several sub-Saharan African countries, including Zambia, have initiated national voluntary medical male circumcision (MC) programs to reduce HIV incidence. In-depth interviews were conducted with twenty female sex workers (FSWs) in Lusaka to examine their understanding of MC and experiences with circumcised clients. Knowledge of MC was derived primarily through informal sources, with very few FSWs reporting exposure to MC educational campaigns. MC was not widely believed to be protective against HIV, however it was viewed by some as protective against STIs. Three FSWs reported having sex with recently circumcised clients, and most reported that men often used their MC status to try to convince FSWs to forego condoms. Findings suggest that FSWs, already at high risk for HIV infection, may face additional pressure toward higher risk behavior as a result of MC. As MC services are expanded, programs should support FSWs' efforts to protect themselves by providing information about what MC can--and cannot--offer for HIV/STI infection prevention.