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BACKGROUND: Decentralized management approaches for multi-drug-resistant tuberculosis (MDR TB) have shown improved treatment outcomes in patients. However, challenges remain in the delivery of decentralized MDR TB services. Further, implementation strategies for effectively delivering the services in community health systems (CHSs) in low-resource settings have not been fully described, as most strategies are known and effective in high-income settings. Our research aimed to delineate the specific implementation strategies employed in managing MDR TB in Zambia. METHODS: Our qualitative case study involved 112 in-depth interviews with a diverse group of participants, including healthcare workers, community health workers, patients, caregivers, and health managers in nine districts. We categorized implementation strategies using the Expert Recommendations for Implementing Change (ERIC) compilation and later grouped them into three CHS lenses: programmatic, relational, and collective action. RESULTS: The programmatic lens comprised four implementation strategies: (1) changing infrastructure through refurbishing and expanding health facilities to accommodate management of MDR TB, (2) adapting and tailoring clinical and diagnostic services to the context through implementing tailored strategies, (3) training and educating health providers through ongoing training, and (4) using evaluative and iterative strategies to review program performance, which involved development and organization of quality monitoring systems, as well as audits. Relational lens strategies were (1) providing interactive assistance through offering local technical assistance in clinical expert committees and (2) providing support to clinicians through developing health worker and community health worker outreach teams. Finally, the main collective action lens strategy was engaging consumers; the discrete strategies were increasing demand using community networks and events and involving patients and family members. CONCLUSION: This study builds on the ERIC implementation strategies by stressing the need to fully consider interrelations or embeddedness of CHS strategies during implementation processes. For example, to work effectively, the programmatic lens strategies need to be supported by strategies that promote meaningful community engagement (the relational lens) and should be attuned to strategies that promote community mobilization (collective action lens).

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BACKGROUND: Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia. METHODS: A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance. FINDINGS: The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation. CONCLUSIONS: Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

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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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BACKGROUND: Over the years, low-and middle-income countries have adopted several policy initiatives to strengthen community health systems as means to attain Universal Health Coverage (UHC). In this regard, Zambia passed a Community Health Strategy in 2017 that was later halted in 2019. This paper explores the processes that led to the halting and re-issuing of this strategy with the view of drawing lessons to inform the development of such strategies in Zambia and other similar settings. METHODS: We employed a qualitative case study comprising 20 semi-structured interviews with key stakeholders who had participated in either the development, halting, or re-issuing of the two strategies, respectively. These stakeholders represented the Ministry of Health, cooperating partners and other non-government organizations. Inductive thematic analysis approach was used for analysis. RESULTS: The major reasons for halting and re-issuing the community health strategy included the need to realign it with the national development framework such as the 7th National Development Plan, lack of policy ownership, political influence, and the need to streamline the coordination of community health interventions. The policy process inadequately addressed the key tenets of community health systems such as complexity, adaptation, resilience and engagement of community actors resulting in shortcomings in the policy content. Furthermore, the short implementation period, lack of dedicated staff, and inadequate engagement of stakeholders from other sectors threatened the sustainability of the re-issued strategy. CONCLUSION: This study underscores the complexity of community health systems and highlights the challenges these complexities pose to health policymaking efforts. Countries that embark on health policymaking for community health systems must reflect on issues such as persistent fragmentation, which threaten the policy development process. It is crucial to ensure that these complexities are considered within similar policy engagement processes.

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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.

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BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

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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.

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INTRODUCTION: Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents. METHODS: Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis. RESULTS: We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges. CONCLUSION: Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

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ABSTRACT: This study examined the association of various forms of social support, attitudes toward living at home, and HIV stigma experiences with HIV self-disclosure efficacy and perceived negative disclosure outcomes. We analyzed cross-sectional data from 120 young people with HIV (YPWH) aged 18-21 years receiving outpatient care in Eastern Province, Zambia. Perceived negative disclosure outcomes and disclosure self-efficacy were measured using an adapted version of the Adolescent HIV Disclosure Cognitions and Affect Scale. Explanatory variables included parental or caregiver support, emotional support, instrumental support, HIV stigma experiences, and attitudes toward living at home. Findings suggest that YPWH's confidence in their ability to self-disclose their HIV status and their assessment of negative outcomes associated with HIV disclosure are influenced by emotional support, experiences of HIV stigma, and the quality of the home environment.

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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.

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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.

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Hydrocele which is caused by long term lymphatic filariasis infection can be treated through the provision of surgery. Access to surgeries remains low particularly for hard to reach populations. This study applied community health system lenses to identify determinants to the adoption, implementation and integration of hydrocele surgeries among migrants &mobile populations in Luangwa District, Zambia. A concurrent mixed methods design consisting of cross-sectional survey with hydrocele patients (n = 438) and in-depth interviews with different community actors (n = 38) was conducted in October 2021. Data analysis was based on the relational and programmatic lenses of Community Health Systems. Under the Programmatic lens, insufficient resources resulted in most health facilities being incapable of providing the minimum package of care for lymphatic filariasis. The absence of cross border collaborative structures limits the continuity of care for patients moving across the three countries. Other programmatic barriers include language barriers, inappropriate appointment systems, direct and indirect costs. In the relational lens, despite the key role that community leaders play their engagement in service delivery was low. Community actors including patients were rarely included in planning, implementation or evaluation of hydrocele services. Some patients utilized their power within to act as champions for the surgery but local groups such as fishing associations remained underutilized. Community health systems provide a potential avenue through which access amongst mobile and migrant populations can be enhanced through strategies such engagement of patient groups, knowledge sharing across borders and use of community monitoring initiatives.

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BACKGROUND: The World Health Organization has promoted a shift towards the test-and-treat-all strategy to accelerate the elimination of HIV/AIDS. Zambia was one of the early African countries to adopt this strategy as the policy change was officially announced on national television by the republican president on 15th August 2017. This study explored the communication and implementation challenges of the HIV/AIDS policy change to test-and-treat-all in selected public health facilities in Lusaka District, Zambia. METHODS: A qualitative case study design was employed with a purposeful sample of policy makers, international partners, National AIDS Council representatives, health facility managers, and frontline health providers in selected tertiary, secondary and primary health facilities in the Lusaka District, Zambia. Thematic data analysis was performed using NVivo 12 Pro software. RESULTS: In total, 22 key informant interviews and 3 focus group discussions were conducted. The government relied on formal and informal channels to communicate the test-and-treat-all policy change to health providers. Whilst HIV policy changes were reflected in the National HIV/AIDS Strategic Framework, there was little awareness of this policy by the frontline providers. The use of informal communication channels such as verbal and text instructions affected health providers' implementation of the test-and-treat-all. Electronic and print media were ineffective in communicating the test-and-treat-all policy change to some sections of the public. Top-down stakeholder engagement, limited health worker training, and poor financing negatively affected the implementation of the test-and-treat-all policy change. Acceptability of the test-and-treat-all policy change was shaped by positive provider perceptions of its benefits, limited sense of policy ownership, and resistance by the non-treatment-ready patients. Furthermore, unintended consequences of the test-and-treat-all policy change on human resources for health and facility infrastructure were reported. CONCLUSION: Effective test-and-treat-all policy change communication is vital for successful policy implementation as it enhances interpretation and adoption among health providers and patients. There is a need to enhance collaboration among policy makers, implementers and the public to develop and apply communication strategies that facilitate the adoption of the test-and-treat-all policy changes to sustain gains in the fight against HIV/AIDS.

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BACKGROUND: The Framework Convention on Tobacco Control (FCTC) requires countries to develop and implement multi-sectoral tobacco control strategies, including policies and legislation. Zambia, potentially faced by a rising problem of tobacco smoking, signed the FCTC in 2008 but has been unable to enact a tobacco policy for over a decade. OBJECTIVE: This study explores the role of 'principled engagement', a key element of the theoretical framework for collaborative governance, in Zambia's delayed success to develop a comprehensive tobacco control policy. METHODS: This was a qualitative case study of key stakeholders in the collaborative process of trying to develop a tobacco policy in Zambia. Participan-ts were sampled from across various sectors, including government departments and civil society, comprising anti-tobacco activists and researchers. A total of 27 key informant interviews were undertaken. We supplemented the interview data with a document review of relevant policies and legislation. Data were analysed using thematic analysis. RESULTS: Several factors hindered efforts to attain principled engagement, including the adverse legal and socioeconomic environment in which the collaborative regime evolves; poor planning of meetings and frequent changes in tobacco focal point persons; lack of active and meaningful participation; and communication challenges among the key stakeholders. These collaborative dynamics, coupled with the opposition to tobacco control efforts from within some government departments, revealed the inadequacy of the current collaborative governance regime to facilitate enactment of a comprehensive tobacco control policy in Zambia. CONCLUSION: Efforts to develop a comprehensive tobacco control policy in Zambia will require addressing challenges such as disagreements, communication, and leadership at engagement level across interested sectors. We further argue that principled engagement has a greater role to play in unlocking these efforts and should therefore be embraced by those entrusted to lead the process to develop tobacco policy in Zambia.

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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.

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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.

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OBJECTIVE: Since introduction of the programme in April 2021, COVID-19 vaccine uptake has been low at less than 20%. This study explored community members' and health workers' perspectives on the COVID-19 vaccine uptake and its influencing factors in Zambia. STUDY DESIGN: A qualitative study employing focus group discussions (FGDs) and in-depth interviews (IDIs). STUDY SETTING: Sixteen primary healthcare facilities selected from Lusaka, Copperbelt, Central and Southern provinces. PARTICIPANTS: A total of 32 FGDs comprising local community members and 30 IDIs including health workers, traditional, religious and civic leaders (n=272). FGDs were separated based on age (youth and adults), sex (male and female) and place of residence (urban and rural). RESULTS: Both FGD and IDI participants agreed that vaccine uptake was low. Limited knowledge, access to information, myths and misconceptions, negative attitude, low-risk perception and supply in remote areas affected vaccine uptake. Overall, FGD participants expressed limited knowledge about the COVID-19 vaccine compared with health workers. Further, FGD participants from urban sites were more aware about the vaccine than those from rural areas. Health workers perceived the vaccine to be beneficial; the benefits included prevention of infection and limiting the severity of the disease. Moreover, FGD participants from urban sites expressed a negative attitude towards the vaccine. They believed the vaccine conferred no benefits. By contrast, participants from rural communities had mixed views; they needed more information about the vaccine benefits. Participants' attitude seems to have been influenced by personal or family experience with the COVID-19 disease or vaccination; those who had experienced the disease had a more positive attitude. In contrast, most young people believed they were not at risk of the COVID-19 disease. Misinformation from social media influenced their attitude. CONCLUSION: These results provide starting points for future policies and interventions for increasing COVID-19 vaccine uptake.

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BACKGROUND: Tuberculosis has remained a leading cause of death among people living with HIV (PLHIV) globally. Isoniazid preventive therapy (IPT) is the recommended strategy by the World Health Organization to prevent TB disease and related deaths among PLHIV. However, delivery and uptake of IPT has remained suboptimal particularly in countries where HIV and TB are endemic such as Tanzania. This study sought to assess contextual factors that shape delivery and uptake of IPT in Dar es Salaam region, Tanzania. METHODOLOGY: We employed a qualitative case study design comprising of in-depth interviews with people living with HIV (n = 17), as well as key informant interviews with clinicians (n = 7) and health administrators (n = 7). We used thematic data analysis approach and reporting of the results was guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Characteristics of IPT such as aligning the therapy to individual patient schedules and its relatively low cost facilitated its delivery and uptake. On the contrary, perceived adverse side effects negatively affected the delivery and uptake of IPT. Characteristics of individuals delivering the therapy including their knowledge, good attitudes, and commitment to meeting set targets facilitated the delivery and uptake of IPT. The process of IPT delivery comprised collective planning and collaboration among various facilities which facilitated its delivery and uptake. Organisational characteristics including communication among units and supportive leadership facilitated the delivery and uptake of IPT. External system factors including HIV stigma, negative cultural and religious values, limited funding as well as shortage of skilled healthcare workers presented as barriers to the delivery and uptake of IPT. CONCLUSION: The factors influencing the delivery and uptake of IPT among people living with HIV are multifaceted and exist at different levels of the health system. Therefore, it is imperative that IPT program implementers and policy makers adopt multilevel approaches that address the identified barriers and leverage the facilitators in delivery and uptake of IPT at both community and health system levels.

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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.

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BACKGROUND: Tuberculosis (TB) is the leading cause of death from a single infectious agent globally, killing about 1.5 million people annually, yet 3 million cases are missed every year. The World Health Organization recommends systematic screening of suspected active TB patients among those visiting the healthcare facilities. While many countries have scaled-up systematic screening of TB, there has been limited assessment of the extent of its integration into the health system. This study sought to explore factors that shape the integration of systematic screening of TB in outpatient departments of primary healthcare facilities in Kitwe district, Zambia. METHODS: This was a qualitative case study with health providers including district managers, TB focal point persons and laboratory personnel working in six purposively selected primary healthcare facilities. Data was collected through key informant (n = 8) and in-depth (n = 15) interviews. Data analysis was conducted using QDA Miner software and guided by Atun's Integration framework. RESULTS: The facilitators to integration of systematic screening for TB into out patient departments of primary health facilities included the perceived high burden TB, compatibility of the systematic screening for TB program with healthcare workers training and working schedules, stakeholder knowledge of each others interest and values, regular performance management and integrated outreach of TB screening services. Constraining factors to integration of systematic screening for TB into outpatient departments included complexity of screening for TB in children, unbalanced incentivization mechanisms, ownership and legitimacy of the TB screening program, negative health worker attitudes, social cultural misconceptions of TB and societal stigma as well as the COVID-19 pandemic. CONCLUSION: Systematic screening of TB is not fully integrated into the primary healthcare facilities in Zambia to capture all those suspected with active TB that make contact with the health system. Finding the missing TB cases will, therefore, require contextual adaptation of the systematic screening for TB program to local needs and capacities as well as strengthening the health system.

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