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.

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.

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.

Experiences of teachers and community health workers implementing sexuality and life skills education in youth clubs in Zambia.

Zambia, like other low- and middle-income countries, faces numerous adolescent sexual and reproductive health challenges such as teenage pregnancies. This study aimed at understanding teachers' and community health workers' (CHWs) implementation of comprehensive sexuality education (CSE) as part of a comprehensive support package for adolescent girls to prevent early childbearing. Data collected using in-depth interviews [n = 28] with teachers [n = 15] and community health workers [n = 13] were analysed using thematic analysis. The teachers and CHWs reported that the use of participatory approaches and collaboration between them in implementing CSE enabled them to increase girls' and boys' participation youth clubs. However, some teachers and CHWs experienced practical challenges with the manuals because some concepts were difficult to understand and translate into local language. The participants perceived that the youth club increased knowledge on CSE, assertiveness and self-esteem among the learners. Training and providing a detailed teaching manual with participatory approaches for delivering CSE, and collaborative teaching enabled teachers and CHWs to easily communicate sensitive SRH topics to the learners. However, for the adoption of CSE to be even more successful, piloting of the curriculum with local facilitators and translating the manuals into the local languages before they are implemented, is recommended.

Community engagement for the Voluntary Medical Male Circumcision (VMMC) program: an analysis of key stakeholder roles to promote a sustainable program in Zambia.

Background: Within the Voluntary Medical Male Circumcision (VMMC) programme, community engagement has been central in facilitating the acceptance of VMMC, especially in non-circumcising communities. We used the case of the development of community engagement plans for sustainability of VMMC in Zambia to illustrate diversity of stakeholders, their power, roles, and strategies in community engagement. Methods: Data were collected using document review, in-depth interviews (n=35) and focus group discussions (n=35) with community stakeholders, health workers, health centre committees, counsellors, teachers, community volunteers and parents/caregivers. Data were analysed using thematic analysis. The analysis was guided by the power and interest model. Results: Differences were noted between the rural and urban sites in terms of power/influence and interest rating of community stakeholders who could be involved in the sustainability phase of the VMMC response in Zambia. For example, in the urban setting, neighbourhood health committees (NHCs), health workers, leaders of clubs, community health workers (CHWs), radio, television and social media platforms were ranked highest. From this list, social media and television platforms were not highly ranked in rural areas. Some stakeholders had more sources of power than others. Forms or sources of power included technical expertise, local authority, financial resources, collective action (action through schools, churches, media platforms, other community spaces), and relational power.   Key roles and strategies included strengthening and broadening local coordination systems, enhancing community involvement, promoting community-led monitoring and evaluation, through the use of locally recognised communication spaces and channels, facilitating ownership of VMMC, and improving local accountability processes in VMMC activities. Conclusions: By consulting with the most relevant stakeholders, and considering community needs in programme development, the VMMC programme may be able to leverage the community structures and systems to reduce long term demand generation costs for VMMC and increase the acceptability and frequency of male circumcision.