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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., (© 2023. BioMed Central Ltd., part of Springer Nature.)

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., (© 2023. The Author(s).)

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., (© 2022. The Author(s).)

Introduction: This article aimed to analyse constructions of adolescents' sexualities and sexual health and the consequences of these discourses for adolescents' exercise of their sexual reproductive health and rights (SRHR) in rural Zambia., Methods: Interpretative repertoires, which is rooted in discursive psychology was used to analyse data from photo-elicitations interviews and focus group discussions. Our participants included 25 adolescents who participated in a SRHR intervention that aimed to reduce adolescents' pregnancies and early marriages., Results: We identified three interpretative repertories: 1) sex is for mature people in which adolescents positioned themselves as 'immature, and young to engage in sex; 2) gendered respectful behaviours in which what was considered disrespectful (and respectful) behaviour in relation to sexuality were strongly influenced by gender, and more clearly defined for girls than it was for boys. Sexuality was not only about individual choices but about being respectful to parents; and 3) acquiring and using knowledge about sexuality in which adolescents conflicted between having and applying SRHR knowledge., Conclusion: These repertories offer an important context that shape how adolescents negotiate, adopt and resist SRHR interventions. Future interventions that target adolescents' SRHR must aim to address the sexual scripts that serve to erect barriers against positive sexual behaviours, including access to SRHR services that promote safer sex., (© 2022. The Author(s).)

Background: The youths in Zambia have limited access to information concerning Sexual Reproductive Health (SRH) and this puts them at risk of unwanted pregnancies. Talking about other methods of preventing pregnancy or sexually transmitted infections than abstinence is regarded as culturally unacceptable. The Research Initiative to Support the Empowerment of Girls (RISE) is a cluster randomised controlled trial testing the effectiveness of different support packages on teenage pregnancies, early marriages and school drop-out rates. One of the support packages included youth clubs focusing on Comprehensive Sexual and Reproductive Health Education (CSRHE). Although similar interventions have been implemented in other settings, their integration process has been complex and comprehensive assessments of factors shaping acceptability of CSRHE are lacking. This article qualitatively aimed at identifying factors that shaped the acceptability of CSRHE youth clubs in rural schools in Central Province., Method: A qualitative case study was conducted after the youth clubs had been running for a year. Data were gathered through eight focus group discussions with grade eight pupils and eight individual interviews with teachers. Data were analysed using thematic analysis., Results: The perceived advantage and simplicity of the clubs related to the use of participatory learning methods, films and role plays to communicate sensitive reproductive health information made the learners like the youth clubs. Further, the perceived compatibility of the content of the sessions with the science curriculum increased the learners' interest in the youth clubs as the meetings also helped them to prepare for the school examinations. However, cultural and religious beliefs among teachers and parents regarding the use of contraceptives complicated the delivery of reproductive health messages and the acceptability of youth clubs' information among the learners., Conclusion: The study indicated that CSRHE youth clubs may be acceptable in rural schools if participatory learning methods are used and head-teachers, teachers as well as parents appreciate and support the clubs.

Introduction: Community-based sexual reproductive interventions are key in attaining universal health coverage for all by 2030, yet adolescents in many countries still lack health services that are responsive to their sexual reproductive health and rights' needs. As the first step of realist evaluation, this study provides a programme theory that explains how, why and under what circumstances community-based sexual reproductive health interventions can transform (or not) 'ordinary' community-based health systems (CBHSs) into systems that are responsive to the sexual reproductive health of adolescents., Methods: This realist approach adopted a case study design. We nested the study in the full intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Sixteen in-depth interviews were conducted with stakeholders involved in the development and/or implementation of the trial. All the interviews were recorded and analysed using NVIVO version 12.0. Thematic analysis was used guided by realist evaluation concepts. The findings were later synthesized using the Intervention-Context-Actors-Mechanism-Outcomes conceptualization tool. Using the retroduction approach, we summarized the findings into two programme theories., Results: We identified two initial testable programme theories. The first theory presumes that adolescent sexual reproductive health and rights (SRHR) interventions that are supported by contextual factors, such as existing policies and guidelines related to SRHR, socio-cultural norms and CBHS structures are more likely to trigger mechanisms among the different actors that can encourage uptake of the interventions, and thus contribute to making the CBHS responsive to the SRHR needs of adolescents. The second and alternative theory suggests that SRHR interventions, if not supported by contextual factors, are less likely to transform the CBHSs in which they are implemented. At individual level the mechanisms, awareness and knowledge were expected to lead to value clarification', which was also expected would lead to individuals developing a 'supportive attitude towards adolescent SRHR. It was anticipated that these individual mechanisms would in turn trigger the collective mechanisms, communication, cohesion, social connection and linkages., Conclusion: The two alternative programme theories describe how, why and under what circumstances SRHR interventions that target adolescents can transform 'ordinary' community-based health systems into systems that are responsive to adolescents.

Background: Adolescent pregnancy carries both health and economic risks for the pregnant girl and resulting baby, and it is common in Zambia. Providing alternative methods of preventing early pregnancy than abstinence is regarded as culturally and religiously unacceptable in most parts of the country. The community dialogue approach is being tested to address norms and beliefs around early pregnancy, marriage and school dropout, and is based on Paulo Freire's transformative communication approach. The objective of this paper was to understand parents' perspectives on the application of the community dialogue approach in addressing adolescents' early pregnancy and school dropout in a cluster randomized controlled trial in rural Zambia. Methods/design: This was a case study design. We nested the study in the community dialogue intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Dialogue meetings were held and economic support was provided for a period of 27 months from September 2016 until November 2018. We held focus group discussions in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. All the discussions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. Results: The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators' interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health (SRH) topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their SRH values and subsequently made them feel able to communicate about SRH issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children. Conclusion: The study indicated that the community dialogue was appreciated by the parents and helped in addressing cultural barriers to discussing SRH issues between generations. Plain language summary: Adolescent pregnancy carries health and economic risks for the pregnant girl and her baby. However, many adolescent girls in Zambia become pregnant and this is partly due to social norms around fertility and marriage. Community dialogue meetings may be useful in order to discuss norms and beliefs around early pregnancy, marriage and school dropout and encourage reflection around cultural practices in the communities. A cluster randomized controlled trial in rural Zambia tested the effects of organizing community dialogue meetings and providing economic support for families with adolescent girls for a period of 27 months, from 2016 to 2018. The objective of this case study was to understand parents' perspectives on the use of the community dialogue approach. Focus group discussions were held in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. The facilitators' interactive approach in the community meetings coupled with the use of films and role plays, lead to active participation and open discussions about sexual and reproductive health topics during the community dialogue meetings. Group interactions and sharing of experiences made the guardians feel able to communicate about sexual and reproductive health issues with their children. However, cultural and religious beliefs among the parents regarding the use of condoms and contraceptives made it difficult for them to touch upon this topic. [ABSTRACT FROM AUTHOR]

Background: Adolescents face significant barriers to access and utilization of sexual and reproductive health services in many low-income settings, which in turn may be associated with adverse consequences such as early pregnancy, sexually transmitted infections, unsafe abortion and mortality. There is evidence suggesting that limited access to sexual and reproductive health information and services among adolescents contributes to these outcomes. We aimed to find out the factors that affect the fertility of adolescents aged 15 to 19 years in Zambia and to identify possible drivers of adolescents' fertility. Methods: Secondary analysis of the ZDHS 2013/14 data was carried out to find out the factors that affect the fertility rate of adolescents aged 15 to 19 years using multivariate logistic regression (n = 3666). Results: Overall, 23.1% of adolescents had given birth at least once in the 5 years leading to the survey (n = 3666, 99.4% response), and 49.8% were rural-based while 50.2% were urban-based. The median number of schooling was 8 years (IQR 6–10). About 52% of the adolescents were in the poorer, poor and medium wealth quintiles while the other 48% were in the rich and richer quintiles. Factors found to affect fertility include residence, wealth status, educational attainment, marriage and abortion. An urban-based adolescent with a lower socioeconomic status was 2.4 times more likely to give birth compared to rural-based poorer adolescents (aOR = 2.4, 95% CI: 1.5, 3.7, p < 0.001). Although odds of giving birth were much higher among rural-based married adolescents (aOR = 8.0, 95% CI: 5.4, 11.9, p < 0.001) compared to urban married adolescents (aOR = 5.5, 95% CI: 8.3, 16.0, p < 0.001), and these relationships both statistically significant, higher educational attainment (aOR = 0.7, 95% CI: 0.6, 0.8 p < 0.001) and abortion (aOR = 0.3, 95% CI: 0.1, 0.8, p = 0.020) reduced these odds, particularly for rural-based adolescents. Conclusion: Despite response aimed at reducing adolescent fertility, low wealth status, low educational attainment and early marriage remain significant drivers of adolescent fertility in Zambia. There is a need to address sexual and reproductive health needs of urban-based adolescents with a lower socioeconomic status. Plain Language Summary: Adolescents go through serious challenges related to accessing and using sexual and reproductive health services in many low-income settings, and may also be related to negative consequences such as early pregnancy, sexually transmitted infections and unsafe abortion and death. Research has revealed that limited access to sexual and reproductive health information and services among young people contributes to these negative consequences. This analysis aimed to find out the factors that affect the fertility of 3666 adolescents aged 15 to 19 years in Zambia and to identify possible drivers of adolescents' fertility, using the Zambia Demographic and Health Survey conducted in 2013/2014. A little over a quarter of the adolescents had given birth at least once in the five years leading to the survey. About half of the young people were rural-basedwhile the other half were urban-based, with an average of about 8 years in school. The rural-based adolescents had slightly lower average years in school compared to the urban-based; 7 years and 9 years respectively. Living in a rural area, residing in a home with a low wealth status and being married were all linked to higher chances of giving birth, while terminating a pregnancy and having more years of education were linked to lower chances of giving birth among the adolescents. Urban-based adolescents with lower wealth status were also linked to higher chances of giving birth compared to urban-based adolescents with higher wealth status. These results suggest that while residing in rural areas and being married increase the chances of higher fertility, the adolescents in urban areas but with lower wealth status also need interventions aimed at reducing their fertility. [ABSTRACT FROM AUTHOR]

Introduction: The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services. Methods: This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia's legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies. Results: The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today's abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law. Conclusions: We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it. [ABSTRACT FROM AUTHOR]