Understanding inequalities in the coverage of adolescent sexual and reproductive health services: a qualitative case study of the selected regions of Zambia.

Introduction: Despite substantial investment in improving healthcare among adolescents in low- and middle-income countries, barriers to access and utilization of services persist, especially to sexual and reproductive health (SRH) services. In response to adolescents' health service needs due to their vulnerability, interventions aimed at improving access and utilization of sexual and reproductive health services have been implemented in specific regions of Zambia. To highlight progress in the access and the overall delivery of services in Zambia, in the wake of a system-level funding mechanism, this paper aims to understand the accessibility, availability, acceptability and quality (AAAQ) of health services provided to young people. Materials and methods: In a qualitative case study, 48 discussions- 32 individual interviews with stakeholders and 16 focus group discussions, consisting of 128 male and female adolescents were conducted in six districts from Eastern, Southern and Muchinga provinces of Zambia. Interviews were audio-recorded, recordings transcribed verbatim, and transcripts were analysed using deductive thematic analysis, using the AAAQ framework and Atun's framework on integration, as a guide to reporting the findings. Results: We found that adolescents knew of and had access to common commodities and services- male condoms, health education and HIV counselling and testing. However, availability was affected by access-related barriers such as frequent stock-outs and insufficiently trained healthcare providers. In addition, accessibility was more restricted during the COVID-19 pandemic lockdown and compounded by the low acceptability of SRH service among adolescents across all contexts. This led to the use of alternatives such as herbal medicine and maintained common myths and misconceptions. The overall quality was marred by the lack of dedicated spaces for adolescent health services and the lack of information, education and communication (IEC) materials in some spaces. Conclusion: While it was noted that some services were available for adolescents in all the study sites, numerous barriers inhibited access to these services and had an impact on the quality-of-service provision. With the added restriction to SRH service asses for young people, due to the low acceptability of adolescent SRH service use, the overall integration of adolescent SRH interventions into routine service provision was low and can be improved by targeting contextual barriers and maintaining best practices.

Exploring the barriers, facilitators, and opportunities to enhance uptake of sexual and reproductive health, HIV and GBV services among adolescent girls and young women in Zambia: a qualitative study.

INTRODUCTION: Adolescents and young women in low-middle-income countries face obstacles to accessing HIV, Sexual and Reproductive Health (SRH), and related Gender-Based Violence (GBV) services. This paper presents facilitators, opportunities, and barriers to enhance uptake of HIV, GBV, and SRH services among Adolescent Girls and Young Women (AGYW) in selected districts in Zambia. METHODS: This study was conducted in Chongwe, Mazabuka, and Mongu Districts among adolescent girls and young women in Zambia. Key informants (n = 29) and in and out-of-school adolescents and young people (n = 25) were interviewed. Purposive sampling was used to select and recruit the study participants. Interviews were transcribed verbatim, and a content analysis approach was used for analysis. RESULTS: The facilitators that were used to enhance the uptake of services included having access to health education information on comprehensive adolescent HIV and gender-based violence services. Non-governmental organisations (NGOs) were the main source of this information. The opportunities bordered on the availability of integrated approaches to service delivery and strengthened community and health center linkages with referrals for specialised services. However, the researchers noted some barriers at individual, community, and health system levels. Refusal or delay to seek the services, fear of side effects associated with contraceptives, and long distance to the health facility affected the uptake of services. Social stigma and cultural beliefs also influenced the understanding and use of the available services in the community. Health systems barriers were; inadequate infrastructure, low staffing levels, limited capacity of staff to provide all the services, age and gender of providers, and lack of commodities and specialised services. CONCLUSION: The researchers acknowledge facilitators and opportunities that enhance the uptake of HIV, GBV, and SRH services. However, failure to address barriers at the individual and health systems level always negatively impacts the uptake of known and effective interventions. They propose that programme managers exploit the identified opportunities to enhance uptake of these services for the young population.

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.

High Prevalence of Low Birth Weight Babies Born to Pregnant Women Referred to a District Hospital in Rural Zambia.

OBJECTIVES: Low birthweight (LBW) is a significant public health problem in sub-Saharan Africa and LBW in rural Zambia is high. Our study explored the prevalence of LBW for newborns whose mothers were referred from a rural health center to a district referral hospital in Lundazi, Zambia. METHODS: A five-month retrospective record review of Ministry of Health data was performed to examine birthweight characteristics of a convenience sample of newborns from ten facilities referring to one district hospital (n = 234). RESULTS: Among all cases, 21% (n = 49) of newborns were LBW. For LBW newborns, 73% (n = 36) were preterm with mothers having a pregnancy duration of less than 37 weeks. Newborns whose mothers experienced twin pregnancies (p = .021) and prolonged labor (p = .033) were more often LBW. However, regression models demonstrated no difference among newborns with and without LBW for prolonged labor (p = .344) and twin pregnancies (p = .324) when controlling for variables that could interact with the maternal-newborn delivery outcomes. CONCLUSIONS: for Practice Healthcare providers and policy makers need to address the short and long-term effects of LBW throughout the lifecycle in rural Zambia. More maternal-newborn health research is needed to understand the underlying socioeconomic, social, and cultural determinants influencing LBW in rural Zambia.

The Association Between Maternity Waiting Home Use and Maternal-Newborn Knowledge: Latent Class Analysis.

BACKGROUND AND PURPOSE: An exploratory latent class analysis (LCA) was performed assessing the association between maternity waiting home (MWH) use and maternal-newborn care knowledge. METHODS: A two-group comparison design using a face-to-face interview (n = 250) was conducted to understand if MWH use was associated with greater maternal knowledge of newborn care. RESULTS: High levels of maternal knowledge of newborn care were associated with MWH use. Mothers with low levels of knowledge were less likely to use an MWH prior to delivery and more likely to have fewer pregnancies, attend less than four antenatal care (ANC) visits, and receive no education about newborn health problems during ANC. CONCLUSIONS: Nurses need to target younger, primigravida mothers attending fewer ANC visits with educational opportunities while advocating for expansion of health education at MWHs to potentiate long-term benefits for improved maternal-newborn health and delivery outcomes.

The Call for Global Health Research Mentorship for Doctorally Prepared Nurses in Low- and Middle-Income Countries.

Limited research about nursing mentorship in low- and middle-income countries (LMICs) is holding science back. This article describes the strengths and challenges associated with global health research mentorship for doctorally prepared nurses whose scholarship focuses on LMICs. Using reflexive narrative accounts from current and former nurse mentors and nurse mentees who participated in a NIH-funded global health doctoral research program, emerging themes revealed the perspectives of mentors and mentees, producing a global health mentoring model for nursing research mentorship relevant to LMICs. Identified themes, which applied across roles and primary affiliations, included 1) collaborative mentor-mentee relationships and 2) enthusiasm for global health nursing. Our global health nursing research mentor-mentee interaction systems conceptual model focuses on nursing science mentoring in LMICs incorporating interpersonal, institutional, and cultural factors. We describe successful components of global nurse researcher mentorship and summarize directions for future research in the field. Our model can be used to create more effective mentee-centered mentoring for nurses or health professionals conducting global research. To advance science, we encourage doctorally prepared nurses to support mentee-centered research mentorship experiences that are sensitive to the unique needs of interdisciplinary global health scholarship.

Maternal knowledge of essential newborn care in rural Zambia.

Maternity waiting homes (MWHs) may offer an intervention to improve newborn outcomes in rural Zambia. This study compared maternal knowledge of newborn care for women referred from facilities with and without MWHs. Topics assessed included: (1) umbilical cord care; (2) thermal and skin care; (3) nutrition, and; (4) prevention of diarrhea, and; (5) newborn danger signs prompting care-seeking. A two-group comparison design with a convenience sample was employed using a face-to-face interviews at one district hospital. Descriptive, inferential, and multivariate analyses were employed to compare knowledge. Overall, mothers demonstrated newborn care knowledge in accordance with World Health Organization (WHO) guidelines for newborn health and there were no significant differences in maternal knowledge of newborn care practices among MWH and non-MWH users. Younger mothers more often did not know about umbilical cord care, newborn skin care, and newborn danger signs. MWH users went more often for antenatal care than non-MWH users. In both groups, we found as the number of ANC visits increases, odds of answering "Don't know" decreases. This study is the first to assess maternal newborn care knowledge and MWH use in rural Zambia. Both MWH users and non-users in the rural district were knowledgeable about essential newborn care.

Operationalization of the Ecological Systems Theory to Guide the Study of Cultural Practices and Beliefs of Newborn Care in Rural Zambia.

Introduction: A wide gap in knowledge exists about the factors associated with newborn care in rural Zambia. In this year of the nurse and midwife, the purpose of this article is to provide transcultural researchers with an example of how Bronfenbrenner's Ecological Systems Theory (EST) can be used to guide an exploration of the cultural practices, knowledge, and beliefs of newborn care and health-seeking behaviors in rural Zambia. Methodology: Based on the EST, maternal knowledge represents the microsystem while family and community members embody the mesosystem. Health care organization denotes the exosystem with culture representing the macrosystem and health policy the chronosystem. Results: Numerous implications for transcultural nursing practice emerged from this adaptation of the ecological systems approach. Findings reveal a maternal dualism faced by Zambian mothers as they navigate the complex interplay between cultural newborn care practices and evidence-based newborn care promoted by the health care system. Discussion: Based on our proposed operationalization of the EST for a transcultural nursing study, the EST can be applied globally, further validating the theory.

Cultural beliefs and health-seeking practices: Rural Zambians' views on maternal-newborn care.

BACKGROUND: - Far too many newborns die or face serious morbidity in Zambia, as in many other sub-Saharan African countries. New knowledge is needed to enhance our understanding of newborn care and the cultural factors influencing the ways mothers seek newborn care. This study adds to the literature about rural Zambians' cultural beliefs and practices related to newborn care and health-seeking practices that influence maternal-newborn health. OBJECTIVE: - The goal of this study was to describe the factors associated with newborn care in rural Zambia. DESIGN: - Sixty focus groups were conducted. Each group contained a minimum of 8 and maximum of 12 participants. Recruitment was conducted orally by word of mouth through the nurse in charge at the health facilities and village chiefs. SETTING: - Data were collected between June and August 2016 in 20 communities located in Zambia's rural Lundazi (Eastern province), Mansa, and Chembe (Luapula province) Districts. PARTICIPANTS: - The study included community members (n = 208), health workers (n = 225), and mothers with infants younger than 1-year-old (n = 213). FINDINGS: - The following themes emerged. From mothers with infants, the dominant theme concerned traditional and protective newborn rituals. From community members, the dominant theme was a strong sense of family and community to protect the newborn, and from health workers, the major theme was an avoidance of shame. A fourth theme, essential newborn care, was common among all groups. KEY CONCLUSIONS: - Together the themes pointed toward a maternal dualism for mothers in rural Zambia. Mothers with infants in rural Zambia likely experience a dualistic sense of responsibility to satisfy both cultural and health system expectations when caring for their newborns. Mothers are pulled to engage in traditional protective newborn care rituals while at the same time being pushed to attend ANC and deliver at the health facility. These findings can be used to understand how mothers care for their newborns to develop interventions aimed at improving maternal-child health outcomes. IMPLICATIONS FOR PRACTICE: - There were findings about the culture-specific prevention of cough, care of the umbilical cord, and early introduction of traditional porridge that carry implications for nursing practice. There is an obvious need to reinforce the importance of partner testing for STIs during routine ANC even though there is a desire to preserve dignity.

Community Perspectives of a 3-Delays Model Intervention: A Qualitative Evaluation of Saving Mothers, Giving Life in Zambia.

BACKGROUND: Saving Mothers, Giving Life (SMGL), a health systems strengthening approach based on the 3-delays model, aimed to reduce maternal and perinatal mortality in 6 districts in Zambia between 2012 and 2017. By 2016, the maternal mortality ratio in SMGL-supported districts declined by 41% compared to its level at the beginning of SMGL-from 480 to 284 deaths per 100,000 live births. The 10.5% annual reduction between the baseline and 2016 was about 4.5 times higher than the annual reduction rate for sub-Saharan Africa and about 2.6 times higher than the annual reduction estimated for Zambia as a whole. OBJECTIVES: While outcome measures demonstrate reductions in maternal and perinatal mortality, this qualitative endline evaluation assessed community perceptions of the SMGL intervention package, including (1) messaging about use of maternal health services, (2) access to maternal health services, and (3) quality improvement of maternal health services. METHODS: We used purposive sampling to conduct semistructured in-depth interviews with women who delivered at home (n=20), women who delivered in health facilities (n=20), community leaders (n=8), clinicians (n=15), and public health stakeholders (n=15). We also conducted 12 focus group discussions with a total of 93 men and women from the community and Safe Motherhood Action Group members. Data were coded and analyzed using NVivo version 10. RESULTS: Delay 1: Participants were receptive to SMGL's messages related to early antenatal care, health facility-based deliveries, and involving male partners in pregnancy and childbirth. However, top-down pressure to increase health facility deliveries led to unintended consequences, such as community-imposed penalty fees for home deliveries. Delay 2: Community members perceived some improvements, such as refurbished maternity waiting homes and dedicated maternity ambulances, but many still had difficulty reaching the health facilities in time to deliver. Delay 3: SMGL's clinician trainings were considered a strength, but the increased demand for health facility deliveries led to human resource challenges, which affected perceived quality of care. CONCLUSION AND LESSONS LEARNED: While SMGL's health systems strengthening approach aimed to reduce challenges related to the 3 delays, participants still reported significant barriers accessing maternal and newborn health care. More research is needed to understand the necessary intervention package to affect system-wide change.

The role of community volunteers in PMTCT programme: Lessons from selected sites in Zambia to strengthen health education on infant feeding and follow-up of HIV-positive mother-infant pair.

BACKGROUND: A global debate surrounding health care delivery at the lowest level of the community has aroused interest among researchers. In settings where skilled health workforce is scarce, the community relies on volunteers to provide care. AIM: To explore the role of community-based volunteers (CBVs) and their perspectives on human immunodeficiency virus (HIV) and infant feeding to gain insights into the implementation of prevention of mother-to-child transmission (PMTCT) interventions at community level. SETTING: The study was conducted in Lusaka using Ngombe and Chelstone health facilities to recruit participants. Fieldwork took place from January 2014 to September 2014. METHODS: An exploratory descriptive qualitative study employing focus group discussions was conducted with CBVs. Convenient sampling was used to recruit 10 participants from each site. All transcribed interviews were imported into the Nvivo 10 for open coding and analysis. RESULTS: Although the role of community volunteers was to support and teach mothers on infant feeding in relation to HIV, the known cultural norms and practices had a bearing on how they tailored their information on breastfeeding to mothers. However, their link of the community to the health facilities cannot be overemphasised in these settings. CONCLUSION: The role of community volunteers in PMTCT interventions can be strengthened by improving their training through use of appropriate educational materials and support of required resources. Lessons from these sites can inform future research to design communitybased interventions and develop health education materials that are sensitive to cultural norms and practices in this and similar settings.

Analysis of experiences with exclusive breastfeeding among HIV-positive mothers in Lusaka, Zambia.

BACKGROUND: Exclusive breastfeeding in the first 6 months offers protection from postnatal HIV infection but remains low in resource-poor settings. Documentation of experiences with exclusive breastfeeding is needed to strengthen infant feeding counselling by health care workers. OBJECTIVE: To explore HIV-positive mothers' experiences with exclusive breastfeeding during the first 6 months of the infant's life. DESIGN: A health facility- and community-based exploratory qualitative study was conducted among 30 HIV-positive mothers practising exclusive breastfeeding and meeting the selection criteria. In-depth interviews were conducted four times with the same participants at 6 days, 6 weeks, 12 weeks and 18 weeks after giving birth. Interviews were transcribed verbatim and files were imported into QRS NVivo Version 10 for coding, and data were analysed using the framework analysis. RESULTS: We found that mothers were aware of the risks of mother-to-child transmission of HIV through breastmilk and recognised the benefits of exclusive breastfeeding to their exposed babies. However, they were particularly concerned about achieving HIV-free survival for their exposed infants because of problems faced during the first 6 months of infant feeding. Although they reported being supported by their families and/or friends, their poor health and nutrition impacted how well they cared for their infants' well-being. CONCLUSIONS: We conclude that exclusive breastfeeding was difficult to achieve because of individual circumstances. Therefore, prevention of mother-to-child transmission interventions that adopt a once-off infant feeding counselling do not achieve adequate preparation on the part of mothers to practice exclusive breastfeeding. There is a need to provide frontline health care workers with steps for consideration during infant feeding counselling.