A critical discourse analysis of adolescent fertility in Zambia: a postcolonial perspective.

BACKGROUND: Despite global and regional policies that promote the reduction of adolescent fertility through ending early marriages and reducing early child-bearing, adolescent fertility remains high in most sub-Saharan countries. This study aimed to explore the competing discourses that shape adolescent fertility control in Zambia. METHODS: A qualitative case study design was adopted, involving 33 individual interviews and 9 focus group discussions with adolescents and other key-informants such as parents, teachers and policymakers. Thematic and critical discourse analysis were used to analyze the data. RESULTS: Adolescents' age significantly reduced their access to Sexual and Reproductive Health, SRH services. Also, adolescent fertility discussions were influenced by marital norms and Christian beliefs, as well as health and rights values. While early marriage or child-bearing was discouraged, married adolescents and adolescents who had given birth before faced fewer challenges when accessing SRH information and services compared to their unmarried or nulliparous counterparts. Besides, the major influencers such as parents, teachers and health workers were also conflicted about how to package SRH information to young people, due to their varying roles in the community. CONCLUSION: The pluralistic view of adolescent fertility is fueled by "multiple consciousnesses". This is evidenced by the divergent discourses that shape adolescent fertility control in Zambia, compounded by the disempowered position of adolescents in their communities. We assert that the competing moral worlds, correct in their own right, viewed within the historical and social context unearth significant barriers to the success of interventions targeted towards adolescents' fertility control in Zambia, thereby propagating the growing problem of high adolescent fertility. This suggests proactive consideration of these discourses when designing and implementing adolescent fertility interventions.

Community health workers at the dawn of a new era.

BACKGROUND: There is now rapidly growing global awareness of the potential of large-scale community health worker (CHW) programmes not only for improving population health but, even more importantly, for accelerating the achievement of universal health coverage and eliminating readily preventable child and maternal deaths. However, these programmes face many challenges that must be overcome in order for them to reach their full potential. FINDINGS: This editorial introduces a series of 11 articles that provide an overview highlighting a broad range of issues facing large-scale CHW programmes. The series addresses many of them: planning, coordination and partnerships; governance, financing, roles and tasks, training, supervision, incentives and remuneration; relationships with the health system and communities; and programme performance and its assessment. Above all, CHW programmes need stronger political and financial support, and this can occur only if the potential of these programmes is more broadly recognized. The authors of the papers in this series believe that these challenges can and will be overcome-but not overnight. For this reason, the series bears the title "Community Health Workers at the Dawn of a New Era". The scientific evidence regarding the ability of CHWs to improve population health is incontrovertible, and the favourable experience with these programmes at scale when they are properly designed, implemented, and supported is compelling. CHW programmes were once seen as a second-class solution to a temporary problem, meaning that once the burden of disease from maternal and child conditions and from communicable diseases in low-income countries had been appropriately reduced, there would be no further need for CHWs. That perspective no longer holds. CHW programmes are now seen as an essential component of a high-performing healthcare system even in developed countries. Their use is growing rapidly in the United States, for instance. And CHWs are also now recognized as having a critically important role in the control of noncommunicable diseases as well as in the response to pandemics of today and tomorrow in all low-, middle-, and high-income countries throughout the world. CONCLUSION: The promise of CHW programmes is too great not to provide them with the support they need to achieve their full potential. This series helps to point the way for how this support can be provided.

Integrating Psychosocial Support for Children in the Education Sector in Zambia: Lessons from the Programme Implementation Process.

Literature suggests that psychosocial support programmes can improve wellbeing and mental health among learners. There is however limited documentation on methodologies and factors that shape integration of such programmes within the education sector. This qualitative study aimed to contribute towards addressing this knowledge gap by analysing the implementation process of the Mainstreaming of Psychosocial Support in the Education Sector programme in Zambia. The study showed that the programme contributed to improved school culture and learning involvement. This transformation led to reduction in school dropout, as well as improved students' wellbeing and performance. These positive results motivated Zambia and other countries to integrate psychosocial support into the education systems. Community engagement, outreach activities, group forums and partnerships were the key programme methodologies that facilitated the integration process. However, limited stakeholder involvement in developing the monitoring process complicated the integration process in the initial stages. In conclusion, effectively facilitating programme integration requires ensuring that the programme is credible, inclusive and has clear implementation guidelines.

Adolescent Mothers' Experiences With Community Health Assistants in Rural Zambia.

Adolescent health demands specific attention because adolescents have the lowest levels of health-care coverage of any age-group globally. The main objective as addressed in this article was to explore the lived experience of adolescent mothers and the services provided to them by community health assistants (CHAs) in rural Zambia. Because the number of adolescent mothers in rural Zambia is so high, it is even more critical to describe the lived experiences of health care among these young women with particular emphasis on primary health care as delivered by CHAs in rural Zambia. We used a mixed-methods design to address our research questions. Data were collected from nine focus groups, which were conducted with young mothers from four provinces and 10 districts (n = 60). To support our effort to better understand the delivery of maternal and child health care in rural Zambia, key informant interviews were conducted with adolescent mothers (n = 12). We also conducted surveys (n = 44) and one-on-one interviews (n = 22) with CHAs. To the best of our knowledge, this is the largest study focused on the intersection of adolescents, maternal child health, and CHA delivery of care in Zambia. The results of our study suggest opportunities for change to operational practices within the rural health-care setting and the need to develop structured and age-appropriate services that focus on adolescents. This work addresses the gap in research for adolescents in health care in rural Zambia and brings attention to the unique health-care needs of adolescent mothers within the rural health-care setting.

"They say that I have lost my integrity by breaking my virginity": experiences of teen school going mothers in two schools in Lusaka Zambia.

BACKGROUND: Adolescent school-going mothers return to school in the rekindled hope of obtaining an education. However, their re-introduction into the school environment requires adequate support from teachers, fellow pupils, and the community. The purpose of this study was to explore the experiences of school-going mothers in Lusaka to understand their coping mechanism in the process of re-integration. METHOD: This is a qualitative case study. We conducted in-depth interviews with 24 school going mothers between the ages of 16-19, purposively selected from 2 schools in Lusaka district. Audio-recorded interviews were transcribed, coded using Nvivo 10 software and analysed using thematic analysis. RESULTS: The girls reported experiencing stigmatization, discrimination, mockery and abuse from their teachers. Some community members labelled, humiliated, gossiped about and isolated the girls from their friends and classmates because of fear of 'contamination'. Families forced some girls into early marriages making them feel rejected. These experiences resulted in low self-esteem, inferiority complex, poor performance in their academic work and identity crises in the young mothers. Therefore, because of the experiences the girls faced, they developed certain behaviours such as beer drinking, truancy and running away from home. They found it difficult to adjust to motherhood while doing their schoolwork. CONCLUSION: There is a need for the teachers to undergo training on how to handle young mothers and have a flexible time-table to accommodate adolescent school going mothers when they miss lessons to attend to their babies. Non-parenting school girls should be counseled so that they do not stigmatize adolescent mothers. Parents need to be educated on how to deal with adolescent mothers in the community. The guidance office should have a qualified psychosocial counselor to help create a conducive learning environment for adolescent mothers, by helping them with missed lessons and seeing to it that they are not stigmatized.

Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process.

INTRODUCTION: Although large scale public sector community health worker programs have been key in providing sexual and reproductive health (SRH) services in low- and middle-income countries, their integration process into community health systems is not well understood. This study aimed to identify the conditions and strategies through which Community Health Assistants (CHAs) gained entry and acceptability into community health systems to provide SRH services to youth in Zambia. The country's CHA program was launched in 2010. METHODOLOGY: A phenomenological design was conducted in Nyimba district. All nine CHAs deployed in Nyimba district were interviewed in-depth on their experiences of navigating the introduction of SRH services for youth in community settings, and the data obtained analyzed thematically. RESULTS: In delivering SRH services targeting youth, CHAs worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders. CHAs delivered SRH education and services in health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and they also worked to build relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. CHAs used their existing social networks to deliver SRH services to adolescents. By embedding the provision of information about SRH into general life skills at community level, the topic's sensitivity was reduced and its acceptability was enhanced. Further, support from community leaders towards CHA-driven services promoted the legitimacy of providing SRH for youth. Factors limiting the acceptability of CHA services included the taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits. CONCLUSION: Strengthening CHAs' ability to negotiate and navigate and gain acceptability in the community health system as they deliver SRH, requires support from both the formal health system and community networks. Limitations to the acceptability of CHA-driven SRH services are a product of challenges both in the community and in the formal health system.

Challenges for health care providers, parents and patients who face a child hood cancer diagnosis in Zambia.

BACKGROUND: Zambia is experiencing high prevalence of childhood cancer. However, very few children access and complete treatment for cancer. This study aimed to document the challenges for health care providers, parents and patients who face a child hood cancer diagnosis in Zambia, and their coping strategies. METHODS: This was an exploratory health facility-based qualitative study that was conducted at a Paediatric oncology ward at referral hospital in Zambia. In-depth individual interviews conducted with fifteen (15) caregivers and seven (7) key informants were analysed using thematic analysis. RESULTS: Several challenges related to managing the childhood cancer diagnosis were recorded. Individual and family challenges were inadequate knowledge on childhood cancer, lack of finances to meet treatment and transport costs as well as long period of hospitalisation that affected women's ability to perform multiple responsibilities. Whereas challenges at community level were inadequate support to address emotional and physical distress and social stigmatisation experienced by caregivers. Health systems issues included inadequate specialised health workers, poor communication among health workers, limited space and beds as well as insufficient supplies such as blood. Cultural related factors were the belief that cancer is a product of witchcraft as well as religious beliefs regarding the role of faith healing in childhood cancer treatment. Coping strategies used by parents/ caregivers included praying to God, material support from organisations and church as well as delaying having another child. CONCLUSION: Addressing the challenges for health care providers, parents and patients who face a childhood cancer diagnosis may require adopting a systems or an ecological approach that allows developing strategies that simultaneously address challenges related to the individual, family, community, health system and cultural aspects.

Experiences of antenatal care among pregnant adolescents at Kanyama and Matero clinics in Lusaka district, Zambia.

BACKGROUND: Adolescent pregnancy is among the many public health concerns not only in Zambia but also in other parts of the world. Exploring pregnant adolescents' experiences of antenatal care may help to identify specific problems and the contextual relevant strategies to improve the access to antenatal care. The purpose of this study was to explore and describe the lived experiences of antenatal care among pregnant adolescents aged between 12 to 19 years old at Kanyama and Matero Referral Clinics in Lusaka district of Zambia. METHODS: This was a qualitative study which used in-depth interviews to collect data. Maximum variation sampling technique was used to select 12 pregnant adolescents of 12 to 19 years age range that attended antenatal care. Data were analysed thematically with the help of Nvivo software version 10. RESULTS: The study revealed that the adolescents experienced positive and negative antenatal care. While there were some reported cases of caring and friendly health care providers and older pregnant women, there were also reported cases of poor attitudes and behaviours by the older pregnant women and health care providers towards the adolescents. In addition, other issues that were reported by the adolescents were the opening hours for the health facilities which was not favourable to all adolescents and the lack of specific spaces for adolescents as well as inadequate privacy and confidentiality. Some solutions were suggested to overcome some of the problems such as reducing the waiting hours or time for consultations at the clinic and to have specific rooms or spaces for pregnant adolescents at the clinic. CONCLUSION: Appropriate interventions targeting pregnant adolescents with emphasis on making antenatal care services more adolescent friendly may improve the quality of and accessibility of antenatal services. The adolescent friendly antenatal services should integrate health promotion activities aimed at sensitising elderly women within the health facilities on the importance of supporting pregnant adolescents.

Ethics challenges and guidance related to research involving adolescent post-abortion care: a scoping review.

INTRODUCTION: An increase in post abortion care (PAC) research with adolescents, particularly in low- and middle-income countries, has brought to attention several associated research ethics challenges. In order to better understand the ethics context of PAC research with adolescents, we conducted a scoping review of published literature. METHODS: Following a systematic search of PubMed, HINARI, and Google Scholar, we analysed articles meeting inclusion criteria to determine common themes across both the ethical challenges related to PAC research with adolescents and any available guidance on the identified challenges. RESULTS: The literature search identified an initial 3321 records of which 14 were included in analysis following screening. Several ethical challenges stem from abortion being a controversial, sensitive, and stigmatized topic in many settings. Ethical dilemmas experienced by researchers conducting adolescent PAC research included: difficulties in convincing local health providers to permit PAC research; challenges in recruiting and seeking consent due to sensitivity of the subject; effectively protecting confidentiality; managing negative effects of interventions; creating a non-prejudicial atmosphere for research; managing emotional issues among adolescents; and dealing with uncertainty regarding the role of researchers when observing unethical health care practices. Suggested strategies for addressing some of these challenges include: using several sources to recruit study participants, using research to facilitate dialogue on abortion, briefing health workers on any observed unethical practices after data collection, fostering a comprehensive understanding of contextual norms and values, selecting staff with experience working with study populations, and avoiding collection of personal identifiers. CONCLUSION: Addressing ethical challenges that researchers face when conducting PAC research with adolescents requires guidance at the individual, institutional, community, and international levels. Overall, despite the documentation of challenges in the published literature, guidance on handling several of these ethics challenges is sparse. We encourage further research to clarify the identified challenges and support the development of formal guidance in this area.

Community based interventions for strengthening adolescent sexual reproductive health and rights: how can they be integrated and sustained? A realist evaluation protocol from Zambia.

BACKGROUND: Research that explores how community-based interventions for strengthening adolescent sexual reproductive health and rights (SRHR) can be integrated and sustained in community health systems, is, to the best of our knowledge, very scarce, if not absent. It is important to document mechanisms that shape integration process in order to improve health systems' responsiveness towards adolescents' SRHR. This realist evaluation protocol will contribute to this knowledge in Zambia where there is increased attention towards promoting maternal, neonatal and child health as a means of addressing the current high early pregnancy and marriage rates. The protocol will ascertain: why, how, and under what conditions the integration of SRHR interventions into Zambian community health systems will optimise (or not) acceptability and adoption of SRHR services. This study is embedded within a randomized controlled trial - "Research Initiative to Support the Empowerment of Girls (RISE)"- which aims to reduce adolescent girl pregnancies and marriages through a package of interventions including economic support to families, payment of school fees to keep girls in school, pocket money for girls, as well as youth club and community meetings on reproductive health. METHODS: This is a multiple-case study design. Data will be collected from schools, health facilities and communities through individual and group interviews, photovoice, documentary review, and observations. The study process will involve 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention that aimed to integrate adolescent SRHR into the community health system may lead to adolescent-friendly services; 2) refining the causal theory through case studies; 3) identifying contextual conditions and mechanisms that shape the integration process; and 4) finally proposing a refined causal theory and set of recommendations to guide policy makers, steer further research, and inform teaching programmes. DISCUSSION: The study will document relevant values as well as less formal and horizontal mechanisms which shape the integration process of SRHR interventions at community level. Knowledge on mechanisms is essential for guiding development of strategies for effectively facilitating the integration process, scaling up processes and sustainability of interventions aimed at reducing SRH problems and health inequalities among adolescents.

Health care needs assessment among adolescents in correctional institutions in Zambia: an ethical analysis.

BACKGROUND: While health care needs assessments have been conducted among juveniles or adolescents by researchers in developed countries, assessments using an ethics framework particularly in developing countries are lacking. We analysed the health care needs among adolescents at the Nakambala Correctional Institution in Zambia, using the Beauchamp and Childress ethics framework. The ethics approach facilitated analysis of moral injustices or dilemmas triggered by health care needs at the individual (adolescent) level. METHODS: The research team utilized 35 in-depth interviews with juveniles, 6 key informant interviews and 2 focus group discussions to collect data. We analysed the data using thematic analysis. The use of three sources of data facilitated triangulation of data. RESULTS: Common health problems included HIV/AIDS, STIs, flu, diarrhoea, rashes, and malaria. Although there are some health promotion strategies at the Nakambala Approved School, the respondents classified the health care system as inadequate. The unfavourable social context which included clouded rooms and lack of adolescent health friendly services unfairly exposed adolescents to several health risks and behaviours thus undermining the ethics principle of social justice. In addition, the limited prioritisation of adolescent centres by the stakeholders and erratic funding also worsened injustices by weakening the health care system. Whereas the inadequate medical and drug supplies, shortage of health workers in the nearby health facilities and weak referral systems excluded the juveniles from enjoying maximum health benefits thus undermining adolescents' wellbeing or beneficence. Inadequate medical and drug supplies as well as non-availability of adolescent friendly health services at the nearest health facility did not only affect social justice and beneficence ethics principles but also threatened juveniles' privacy, liberty and confidentiality as well as autonomy with regard to health service utilisation. CONCLUSION: Adequately addressing the health needs in correctional institutions may require adopting an ethics framework in conducting health needs assessment. An ethics approach is important because it facilitates understanding of moral dilemmas that arise due to health needs. Furthermore, strategies for addressing health needs related to one ethics principle may have a positive ripple effect over other health needs as the principles are intertwined thus facilitating a comprehensive response to health needs.

Banning traditional birth attendants from conducting deliveries: experiences and effects of the ban in a rural district of Kazungula in Zambia.

BACKGROUND: In 2010 the government of the republic of Zambia stopped training traditional birth attendants and forbade them from conducting home deliveries as they were viewed as contributing to maternal mortality. This study explored positive and negative maternal health related experiences and effects of the ban in a rural district of Kazungula. METHODS: This was a phenomenological study and data were collected through focus group discussions as well as in-depth interviews with trained traditional birth attendants (tTBAs) and key informant interviews with six female traditional leaders that were selected one from each of the six zones. All 22 trained tTBAs from three clinic catchment areas were included in the study. Content analysis was used to analyse the data after coding it using NVIVO 8 software. RESULTS: Home deliveries have continued despite the community and tTBAs being aware of the ban. The ban has had both negative and positive effects on the community. Positive effects include early detection and management of pregnancy complications, enhanced HIV/AIDS prevention and better management of post-natal conditions, reduced criticisms of tTBAs from the community in case of birth complications, and quick response at health facilities in case of an emergency. Negatives effects of the ban include increased work load on the part of health workers, high cost for lodging at health facilities and traveling to health facilities, as well as tTBAs feeling neglected, loss of respect and recognition by the community. CONCLUSION: Countries should design their approach to banning tTBAs differently depending on contextual factors. Further, it is important to consider adopting a step wise approach when implementing the ban as the process of banning tTBAs may trigger several negative effects.

"When am I going to stop taking the drug?" Enablers, barriers and processes of disclosure of HIV status by caregivers to adolescents in a rural district in Zambia.

BACKGROUND: Disclosure of adolescents' own HIV status by caregivers is not only challenging but low. The reasons for this remain unclear despite efforts to examine and seek to understand disclosure patterns or factors that may either facilitate or inhibit this disclosure. This study explored the enablers, barriers and processes of disclosure of HIV status to adolescents by their caregivers in Kafue district of Zambia. METHODS: A case study method was used to understand factors that facilitate or inhibit caregiver's ability to disclose the HIV status of adolescents aged 10-15 years. Data collected through in-depth interviews with 30 caregivers as well as 6 key informants were analysed using thematic analysis. RESULTS: Overall, 17 out of 30 (56.7 %) caregivers had informed the adolescents about their HIV status. Reasons for disclosing of the HIV status included inquiries by adolescents as to why they were taking medication, threats by adolescents not to take HIV medication, desire to promote treatment self-efficacy amongst adolescents as well as facilitating adoption of safe sexual behaviour among adolescents. The disclosure processes were conducted either at the home or at the clinic. Enabling factors for HIV disclosure were adolescents' knowledge of HIV and caregivers' knowledge of and experience with HIV programs. Barriers to disclosure of HIV status included fear of psychological trauma for the adolescents, perceived inability of adolescents to keep their HIV status confidential which could attract HIV stigmatisation for the family, and caregivers', fear of being blamed by the adolescents for the infection, limited disclosure skills by caregivers as well as negative attitude by some HIV counsellors. CONCLUSIONS: Despite challenges associated with disclosure of adolescents' own HIV status by caregivers, environments that facilitate this process exist and can be strengthened. Promoting HIV disclosure requires in-depth and context-specific understanding of the factors that enable and undermine this process. Limitations in this understanding may have played critical roles in past strategic implementation of locally driven and relevant interventions to improve disclosure of HIV status by caregivers to adolescents in Zambia.

Increased fairness in priority setting processes within the health sector: the case of Kapiri-Mposhi District, Zambia.

BACKGROUND: The challenge of priority setting (PS) in health care within contexts of severe resource limitations has continued to receive attention. Accountability for Reasonableness (AFR) has emerged as a useful framework to guide the implementation of PS processes. In 2006, the AFR approach to enhance legitimate and fair PS was introduced by researchers and decision makers within the health sector in the EU funded research project entitled 'Response to Accountable priority setting for Trust in health systems' (REACT). The project aimed to strengthen fairness and accountability in the PS processes of health systems at district level in Zambia, Tanzania and Kenya. This paper focuses on local perceptions and practices of fair PS (baseline study) as well as at the evolution of such perceptions and practices in PS following an AFR based intervention (evaluation study), carried out at district level in Kapiri-Mposhi District in Zambia. METHODS: Data was collected using in depth interviews (IDIs), focus group discussions (FGDs) and review of documents from national to district level. The study population for this paper consisted of health related stakeholders employed in the district administration, in non-governmental organizations (NGO) and in health facilities. RESULTS: During the baseline study, concepts of legitimacy and fairness in PS processes were found to be grounded in local values of equity and impartiality. Government and other organizational strategies strongly supported devolution of PS and decision making procedures. However, important gaps were identified in terms of experiences of stakeholder involvement and fairness in PS processes in practice. The evaluation study revealed that a transformation of the views and methods regarding fairness in PS processes was ongoing in the study district, which was partly attributed to the AFR based intervention. CONCLUSIONS: The study findings suggest that increased attention was given to fairness in PS processes at district level. The changes were linked to a number of simultaneous factors among them the concepts introduced by the present project with its emphasis on fairness and enhanced participation. A responsive leadership that was increasingly accountable to its operational staff and communities emerged as one of the key elements in driving the processes forward.

The accountability for reasonableness approach to guide priority setting in health systems within limited resources--findings from action research at district level in Kenya, Tanzania, and Zambia.

BACKGROUND: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). METHODS: This intervention study applied an action research methodology to assess implementation of AFR in one district in Kenya, Tanzania, and Zambia, respectively. The assessments focused on selected disease, program, and managerial areas. An implementing action research team of core health team members and supporting researchers was formed to implement, and continually assess and improve the application of the four conditions. Researchers evaluated the intervention using qualitative and quantitative data collection and analysis methods. RESULTS: The values underlying the AFR approach were in all three districts well-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness to a broadened engagement of health team members and other stakeholders in priority setting and other decision-making processes. CONCLUSIONS: District stakeholders were able to take greater charge of closing the gap between nationally set planning and the local realities and demands of the served communities within the limited resources at hand. This study thus indicates that the operationalization of the four broadly defined and linked conditions is both possible and seems to be responding to an actual demand. This provides arguments for the continued application and further assessment of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications.

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.

Accommodate or Reject: The Role of Local Communities in the Retention of Health Workers in Rural Tanzania.

BACKGROUND: While over 70% of the population in Tanzania reside in rural areas, only 25% of physicians and 55% of nurses serve these areas. Tanzania operates a decentralised health system which aims to bring health services closer to its people through collaborative citizen efforts. While community engagement was intended as a mechanism to support the retention of the health workforce in rural areas, the reality on the ground does not always match this ideal. This study explored the role local communities in the retention of health workers in rural Tanzania. METHODS: An exploratory qualitative study was completed in two rural districts from the Kilimanjaro and Lindi regions in Tanzania between August 2015 and September 2016. Nineteen key informant interviews (KIIs) were conducted with district health managers, local government leaders, and health facility in-charges. In addition, three focus group discussions (FGDs) were conducted with 19 members of the governing committees of three health facilities from the two districts. Data were analysed using the thematic analysis technique. RESULTS: Accommodation or rejection were the two major ways in which local communities influenced the quest for retaining health workers. Communities accommodated incoming health workers by providing them a good reception, assuming responsibility for resolving challenges facing health facilities and health workers, linking health workers to local communities and promoting practices that placed a high value on health workers. On the flip side, communities could also reject health workers by openly expressing lack of trust and labelling them as 'foreigners,' by practicing cultural rituals that health workers feared and discrimination based on cultural differences. CONCLUSION: Fostering good relationships between local communities and health workers may be as important as incentives and other health system strategies for the retention of health workers in rural areas. The role communities play in rural health worker retention is not sufficiently recognized and is worthy of further research.

Norms and sexual relations among adolescents in the context of an intervention trial in rural Zambia.

High levels of adolescent pregnancy and child marriage rates in low- and middle-income countries is an issue of concern to many stakeholders, including in Zambia where almost one-third of women give birth before age 18. The aim of this paper is to explore and analyse social norms concerning adolescents' sexual behaviour within the context of an intervention trial in rural communities in southern Zambia. It is based on a qualitative study applying individual interviews, focus group discussions and participatory research methods. We apply the distinction between injunctive and descriptive norms to demonstrate that adolescent girls are caught between conflicting norms. Injunctive norms express that premarital sex, contraceptive use, and discussions about sex between adults and youths are socially condemned. At the same time poor girls are reported to feel pressure towards having sexual relations for the economic benefits such relations can bring, and this practice is considered so common that it amounts to a descriptive norm. Norms and structural conditions combine to create a disabling and disempowering environment for adolescent sexual and reproductive health, which limits girls' agency and exposes them to unwanted pregnancies.

Unlocking Trust in Community Health Systems: Lessons From the Lymphatic Filariasis Morbidity Management and Disability Prevention Pilot Project in Luangwa District, Zambia.

BACKGROUND: Surgery for hydrocele is commonly promoted as part of morbidity management and disability prevention (MMDP) services for lymphatic filariasis (LF). However, uptake of these surgeries has been suboptimal owing to several community level barriers that have triggered mistrust in such services. This study aimed at documenting mechanisms of unlocking trust in community health systems (CHSs) in the context of a LF hydrocele management project that was implemented in Luangwa District, Zambia. METHODS: Qualitative data was collected through in-depth interviews (IDIs) and focus group discussions (FGDs) (n=45) in February 2020 in Luangwa District. Thirty-one IDIs were conducted with hydrocele patients, community health workers (CHWs), health workers, traditional leaders and traditional healers. Two FGDs were also conducted with CHWs who had been involved in project implementation with seven participants per group. Data was analyzed using a thematic analysis approach. RESULTS: The use of locally appropriate communication strategies, development of community driven referral systems, working with credible community intermediaries as well as strengthening health systems capacity through providing technical and logistical support enhanced trust in surgery for hydrocele and uptake of the surgeries. CONCLUSION: Implementation of community led communication and referral systems as well as strengthening health services are vital in unlocking trust in health systems as such mechanisms trigger authentic partnerships, including mutual respect and recognition in the CHS. The mechanisms also enhance confidence in health services among community members.

Exploring Politics and Contestation in the Policy Process: The Case of Zambia's Contested Community Health Strategy.

There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia's 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.