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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.

Background/AimsObstetric fistula is a serious birthing injury with medicosocial consequences including infertility and marital disharmony. Obstetric fistula has been eliminated in developed countries but remains highly prevalent in Africa and Asia. The aim of this study was to identify and analyse the marital experiences of women with obstetric fistula in order to guide interventions to help women cope with their situation, as well as improving partner support towards women living with this condition.MethodsA range of electronic databases were searched for studies conducted worldwide, published between 2003 and 2018. English language publications were searched for using relevant keywords. Three main themes were identified based on the content of the interview questions and the respondents' views and experiences, and how these related to the study objectives.ResultsA total of 33 studies were included. Three main themes in the marital experiences of women with obstetric fistulas were identified: ‘loss of marriage’ (n=25), ‘marital and sexual life is no longer joyful’ (n=17), and ‘partner support’ (n=22).ConclusionsObstetric fistula can have significant impacts on a woman and her partner. Healthcare professionals should be aware of these concerns and surgical repair should be encouraged. Counselling should be provided for women with obstetric fistula and their partners.

ABSTRACTBackgroundThe 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.ObjectiveThis 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.MethodsThis 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.ResultsSeveral 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.ConclusionEfforts 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.

Background:In order to address the challenges facing the community-based health workforce in Zambia, its Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called ‘community health assistants’ (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work.Methods:A phenomenological approach was used to examine CHAs' experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district, Zambia, and observations were analysed using a thematic analysis approach.Results:Personal characteristics, such as previous experience and knowledge, passion to serve the community and a desire to improve skills, motivated people to become CHAs. Health systems characteristics, such as an inclusive work culture in some health posts, motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure that constrained CHAs' ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs' ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected some CHAs' self-confidence and professional outlook.In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs, which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers, due to their exclusion from the government payroll, inhibited CHAs' ability to deliver services.Conclusions:Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

ABSTRACTBackground: Cash Transfer (CT) schemes have become popular poverty reducing measures in many low and middle-income countries. Research indicates that when provided to girls in resource poor settings, cash transfers can increase education and postpone marriage and pregnancy. However, a few studies indicate that they can also have negative effects which can affect their acceptability, such as generating intra-community tensions.Objective: Conceptually informed by Rogers’ diffusion of innovation theory, this paper explores factors affecting the acceptability of economic support in a randomized controlled trial in rural Monze and Pemba Districts of Southern Province in Zambia.Methods: Qualitative data were collected through five focus group discussions and six in-depth, semi-structured interviews and analysed using thematic analysis. This study was done in the combined arm of a trial where girls received both economic support and participated in youth clubs offering sexuality and life-skills education.Results: In the study communities, acceptability was encouraging by the belief that economic support provided benefits beyond beneficiaries and that it improved access to education, and reduced teen pregnancies, marriages and school drop-out. However, provision of economic support only to selected girls and their parents and fear among some that the support was linked to satanic practices negatively affected acceptability. These fears were mitigated through community sensitisations.Conclusion: The study demonstrated that relative advantage, observability, simplicity and compatibility were key factors in influencing acceptability of the economic support. However, to enhance acceptability of cash transfer schemes aimed at addressing early marriage and pregnancy, it is important to explore socio-cultural factors that create suspicions and negative perceptions and to provide schemes that are perceived as relatively better than available similar schemes, understood, compatible and viable beyond the immediate beneficiary.

ABSTRACTBackground: The SAFE strategy (surgery for trichiasis, antibiotics for active infection, facial cleanliness and environmental improvement) is the World Health Organization (WHO) recommended guideline for the elimination of blindness by trachoma by the year 2020.Objective: While evaluations on the implementation of the SAFE strategy have been done, systematic reviews on the factors that have shaped implementation are lacking. This review sought to identify these factors.Methods: We searched PUBMED, Google Scholar, CINAHL and Cochrane Collaboration to identify studies that had implemented SAFE interventions. The Consolidated Framework for Implementation Research (CFIR) guided development of the data extraction guide and data analysis.Results: One hundred and thirty-seven studies were identified and only 10 papers fulfilled the eligibility criteria. Characteristics of the innovation– such as adaptation of the SAFE interventions to suit the setting and observability of positive health outcomes from pilots – increased local adoption. Characteristics of outer setting– which included strong multisectoral collaboration – were found to enhance implementation through the provision of resources necessary for programme activities. When community needs and resources were unaccounted for there was poor compatibility with local settings. Characteristics of the inner setting– such as poor staffing, high labour turnovers and lack of ongoing training – affected health workers’ implementation behaviour. Implementation climate within provider organisations was shaped by availability of resources. Characteristics of individuals– which included low knowledge levels – affected the acceptability of SAFE programmes; however, early adopters could be used as change agents. Finally, the use of engagement strategies tailored towards promoting community participation and stakeholder involvement during the implementation processfacilitated adoption process.Conclusion: We found CFIR to be a robust framework capable of identifying different implementation determinants in low resource settings. However, there is a need for more research on the organisational, provider and implementation process related factors for trachoma as most studies focused on the outer setting.