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Zulu JM, Crankshaw TL, Ouedraogo R, Juma K, Aantjes CJ. "The ones at the bottom of the food chain": structural drivers of unintended pregnancy and unsafe abortion amongst adolescent girls in Zambia. Arch Public Health 2024; 82:137. [PMID: 39187865 PMCID: PMC11346015 DOI: 10.1186/s13690-024-01377-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 08/17/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Access to safe abortion care is highly unequal and fundamentally rooted in socioeconomic inequalities which are amplified by restrictive social norms and legal systems. We analyse these inequalities along the reproductive health continuum amongst adolescent girls in Zambia. METHODOLOGY This paper draws from 20 focus group discussions conducted in 2021 with community members (young/adult) in five urban, peri urban, and rural sites in Zambia. Data was analysed using thematic analysis. RESULTS Adolescent pregnancy in the community was reported to be very common across the communities with girls from poorer families being disproportionately affected. Parents were reported to be complicit in facilitating their daughter's sexual-economic exchanges which emerged as a key driver of pregnancies. Young age and unmarried status meant adolescent girls could face triple stigma: stigma around accessing contraception to prevent a pregnancy, stigma in experiencing an unintended pregnancy and stigma around terminating an unintended pregnancy. There were clear socioeconomic differences in adolescent girl's exposure to community and health provider censure and/or acceptance of their pregnancy, and in their ability to conceal an abortion. Having the means to pay for health care allows some adolescents to seek terminations earlier and to access private health facilities while poorer adolescent girls face greater exposure to community censure through their embeddedness within the community. Abortions in this group attracts greater visibility through complications arising from their constrained choice for safe abortion methods. Stigmatising attitudes of community members also undermined adolescents' reproductive agency and mental health. For adolescents who choose to keep an unintended pregnancy, reintegration into school was highly challenging despite a national policy in place, with marriage being viewed as the only future option for poorer teenage mothers. CONCLUSION The embeddedness of adolescent pregnancies within community structures of economic insecurity and gendered and age-related power relations highlight the importance of introducing community level approaches to tackle unintended pregnancies and unsafe abortion. Understanding teenage pregnancy as a community issue creates opportunities for community level support to young girls especially when they return to school.
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Affiliation(s)
- Joseph Mumba Zulu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia.
- Department of Health Policy and Management, School of Public Health, University of Zambia, PO Box 50110, Lusaka, Zambia.
| | - Tamaryn L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Ramatou Ouedraogo
- African Population and Health Research Center (APHRC), PO Box 10787-00100, Nairobi, Kenya
| | - Kenneth Juma
- African Population and Health Research Center (APHRC), PO Box 10787-00100, Nairobi, Kenya
| | - Carolien J Aantjes
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Olsen SH, Roh EJ, Syakayuwa T, Chola M, Agbakwuru C, Stafford KA, Stoebenau K, Dzekedzeke K, Charurat M. Confluence of crises: COVID-19, "gassings", blood draws and the continued importance of community engagement in Zambia. Health Promot Perspect 2022; 12:67-76. [PMID: 35854852 PMCID: PMC9277288 DOI: 10.34172/hpp.2022.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/24/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Nationally representative, household-based, health-related surveys are an invaluable source of health information, but face implementation challenges. In sub-Saharan Africa, these challenges are exacerbated when surveys include the collection of biological specimens. In this study, we describe the potential implementation challenges identified during field practice leading up to the 2020 Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, and explore the role of two crises on community mistrust of, and apprehension to, participate in the survey. Methods: Using focus group methodology to better understand the influence of crises on ZAMPHIA participation, we conducted 12 focus group discussions (FGDs) in five districts across two provinces. FGDs were conducted with three purposively sampled study groups: recognized household heads, community leaders, and young adults aged 18-24 years. We used reflexive thematic analysis to develop themes from across the FGDs. Results: We identified two key themes: the ever-present threat a stranger posed to the community is enhanced by crises, and endorsement of community awareness through sensitization can mitigate outsider challenges in medical research. Conclusion: We argue that these crises emphasized underlying mistrust that can only be addressed with substantial investment in community engagement efforts to build trust and partnership in medical research endeavors. Our findings underline the importance of prioritizing community engagement through substantial investment in varied and extensive approaches to sensitization to facilitate community engagement toward community acceptance of ZAMPHIA and similar studies.
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Affiliation(s)
- Sara H Olsen
- Department of Behavioral and Community Health, University of Maryland School of Public Health, Maryland, USA
| | - Esther J Roh
- Department of Behavioral and Community Health, University of Maryland School of Public Health, Maryland, USA
| | - Tandwa Syakayuwa
- Center for International Health, Education, and Biosecurity, Zambia
| | - Mumbi Chola
- Center for International Health, Education, and Biosecurity, Zambia
| | - Chinedu Agbakwuru
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Maryland, USA
| | - Kristen A Stafford
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Maryland, USA.,Institute of Human Virology, University of Maryland School of Medicine, Maryland, USA
| | - Kirsten Stoebenau
- Department of Behavioral and Community Health, University of Maryland School of Public Health, Maryland, USA
| | | | - Manhattan Charurat
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Maryland, USA.,Institute of Human Virology, University of Maryland School of Medicine, Maryland, USA
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Kouanda S, Nahyuha Chomi E, Kim C, Jen S, Bahamondes L, Cecatti JG, Lumbiganon P, Emefa M, Brizuela V, Kuganantham H, Seuc AH, Ali M. Health systems analysis and evaluation of the barriers to availability, utilisation and readiness of sexual and reproductive health services in COVID-19-affected areas: a WHO mixed-methods study protocol. BMJ Open 2022; 12:e057810. [PMID: 35649598 PMCID: PMC9160592 DOI: 10.1136/bmjopen-2021-057810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION COVID-19 has led to an unprecedented increase in demand on health systems to care for people infected, necessitating the allocation of significant resources, especially medical resources, towards the response. This, compounded by the restrictions on movement instituted may have led to disruptions in the provision of essential services, including sexual and reproductive health (SRH) services. This study aims to assess the availability of contraception, comprehensive abortion care, sexually transmitted infection prevention and treatment and sexual and gender-based violence care and support services in local health facilities during COVID-19 pandemic. This is a standardised generic protocol designed for use across different global settings. METHODS AND ANALYSIS This study adopts both quantitative and qualitative methods to assess health facilities' SRH service availability and readiness, and clients' and providers' perceptions of the availability and readiness of these services in COVID-19-affected areas. The study has two levels: (1) perceptions of clients (and the partners) and healthcare providers, using qualitative methods, and (2) assessment of infrastructure availability and readiness to provide SRH services through reviews, facility service statistics for clients and a qualitative survey for healthcare provider perspectives. The health system assessment will use a cross-sectional panel survey design with two data collection points to capture changes in SRH services availability as a result of the COVID-19 epidemic. Data will be collected using focus group discussions, in-depth interviews and a health facility assessment survey. ETHICS AND DISSEMINATION Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (protocol ID CERC.0103). Each study site is required to obtain the necessary ethical and regulatory approvals that are required in each specific country.
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Affiliation(s)
- Seni Kouanda
- Reproductive Health Unit, Institute for Research in Health Sciences, Ouagadougou, Burkina Faso
| | - Eunice Nahyuha Chomi
- Reproductive Health Unit, Institute for Research in Health Sciences, Ouagadougou, Burkina Faso
| | - Caron Kim
- Department of Sexual and Reproductive Health, World Health Organization, Geneve, Switzerland
| | - Sothornwit Jen
- Department of Obstetrics and Gynaecology, Khon Kaen University, Nai Mueang, Thailand
| | - Luis Bahamondes
- Department of Obstetrics and Gynaecology, State University of Campinas-UNICAMP, Campinas, Brazil
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Khon Kaen University, Nai Mueang, Thailand
| | - Modey Emefa
- Department of population, family and Reproductive Health, University of Ghana, Legon, Ghana
| | - Vanessa Brizuela
- Department of Sexual and Reproductive Health, World Health Organization, Geneve, Switzerland
| | - Hamsadvani Kuganantham
- Department of Sexual and Reproductive Health, World Health Organization, Geneve, Switzerland
| | - Armando Humberto Seuc
- Department of Sexual and Reproductive Health, World Health Organization, Geneve, Switzerland
| | - Moazzam Ali
- Department of Sexual and Reproductive Health, World Health Organization, Geneve, Switzerland
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Zulu JM, Blystad A, Haaland MES, Michelo C, Haukanes H, Moland KM. Why teach sexuality education in school? Teacher discretion in implementing comprehensive sexuality education in rural Zambia. Int J Equity Health 2019; 18:116. [PMID: 31558168 PMCID: PMC6764121 DOI: 10.1186/s12939-019-1023-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/21/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Reproductive health problems such as HIV, unwanted pregnancy and unsafe abortion among adolescents are closely linked to insufficient knowledge about sexuality and reproduction and lack of access to contraceptives. Supported by international agencies, Zambia has introduced an ambitious nation-wide program for comprehensive sexuality education (CSE) to be implemented into ordinary school activities by teachers. The curriculum is firmly based in a discourse of sexual and reproductive rights, not commonly found in the public debate on sexuality in Zambia. This paper explores how teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia. METHODS Using a case study design, data were collected through in-depth interviews with 18 teachers and analyzed thematically drawing upon theories of discretion and policy implementation. RESULTS Individual teachers make decisions on their own regarding what and when to teach CSE. This discretion implies holding back information from the learners, teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether. Teachers' choices about the CSE program were linked to lack of guidance on teaching of the curriculum, especially with regards to how to integrate sexuality education into existing subjects. Limited prioritization of CSE in the educational sector was observed. The incompatibility of CSE with local norms and understandings about adolescent sexuality combined with teacher-parent role dilemmas emerged as problematic in implementing the policy. Limited ownership of the new curriculum further undermined teachers' motivation to actively include CSE in daily teaching activities. Use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners. CONCLUSION The CSE had limited legitimacy in the community and was met with resistance from teachers tasked with its' implementation. In order to enhance ownership to the CSE program, local concerns about the contents of the curriculum and the parent-teacher role dilemma must be taken into consideration. Not addressing these challenges may undermine the policy's intention of increasing knowledge about sexuality and reproduction and empowering adolescents to access contraceptive services and avoid unwanted pregnancies.
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Affiliation(s)
| | - Astrid Blystad
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Marte E. S. Haaland
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Charles Michelo
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Haldis Haukanes
- Department of Health Promotion and Development, University of Bergen, Bergen, Norway
| | - Karen Marie Moland
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
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Zulu JM, Kinsman J, Hurtig AK, Michelo C, George A, Schneider H. 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. Reprod Health 2019; 16:122. [PMID: 31409362 PMCID: PMC6693243 DOI: 10.1186/s12978-019-0788-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/05/2019] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Joseph M. Zulu
- Department of Public Health, School of Medicine, University of Zambia, School of Public Health, P.O. Box 50110, Lusaka, Zambia
| | - John Kinsman
- Department of Global Health and Epidemiology, Umeå University, 90185 Umeå, SE Sweden
| | - Anna-Karin Hurtig
- Department of Global Health and Epidemiology, Umeå University, 90185 Umeå, SE Sweden
| | - Charles Michelo
- Department of Public Health, School of Medicine, University of Zambia, School of Public Health, P.O. Box 50110, Lusaka, Zambia
| | - Asha George
- School of Public Health and SAMRC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
| | - Helen Schneider
- School of Public Health and SAMRC Health Services to Systems Unit, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, 7535 South Africa
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Zulu JM, Sandøy IF, Moland KM, Musonda P, Munsaka E, Blystad A. The challenge of community engagement and informed consent in rural Zambia: an example from a pilot study. BMC Med Ethics 2019; 20:45. [PMID: 31272489 PMCID: PMC6610979 DOI: 10.1186/s12910-019-0382-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/19/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There is a need for empirically based research on social and ethical challenges related to informed consent processes, particularly in studies focusing on adolescent sexual and reproductive health. In a pilot study of a school-based pregnancy prevention intervention in rural Zambia, the majority of the guardians who were asked to consent to their daughters' participation, refused. In this paper we explore the reasons behind the low participation in the pilot with particular attention to challenges related to the community engagement and informed consent process. METHODS The pilot was implemented in two schools and examined the acceptability of a package of interventions including economic support to families to keep their girls in school, pocket money for girls, youth club meetings on reproductive health, and community meetings to sensitize the community. Focus group discussions (4) were conducted with girls who participated in the pilot, boys in their class and with parents. Individual semi-structured interviews (11) were conducted with teachers, peer educators and community health workers involved in the coordination of the intervention as well as with religious and traditional leaders. Data were analyzed through thematic analysis. RESULTS The findings indicate that inadequate use of recognized community communication channels during the community engagement process and dissemination of information about the pilot resulted in limited understanding of the pilot concept by the community. This surfaced through uncertainty and fear that the intervention may result in loss of control over daughters, worries about why money was provided unconditionally to girls, and suspicion of links to satanism. The sense of insecurity appeared to be exacerbated by low literacy levels, poverty, fear of loss of bride wealth, perceived disregard for local perceptions of social status, and scanty trust in the actors implementing the pilot. CONCLUSIONS Inadequate use of locally appropriate channels in the dissemination of information created room for interpretation and facilitated development of mistrust, undermining the conditions for community engagement and actual informed consent. A key lesson learnt is the importance of taking seriously the complexity of local values and structures that may impact people's capability to consent or not consent to a study in an informed manner.
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Affiliation(s)
- Joseph Mumba Zulu
- University of Zambia, School of Public Health, P.O. Box 50110, Lusaka, Zambia
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
| | - Ingvild Fossgard Sandøy
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
| | - Karen Marie Moland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
| | - Patrick Musonda
- University of Zambia, School of Public Health, P.O. Box 50110, Lusaka, Zambia
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
| | - Ecloss Munsaka
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
- University of Zambia, School of Education, Lusaka, Zambia
| | - Astrid Blystad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Center for Intervention Science in Maternal and Child Health (CISMAC),Centre for International Health (CIH), University of Bergen, Bergen, Norway
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