Umeå University's logo

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.

Background: This study adopts a community health systems approach to analyse two models of sexual and reproductive health and rights programmes targeting school-going adolescents and young people in rural Zambia. The primary aim is to evaluate these programmes, which are designed to enhance sexual and reproductive health and rights among this population, through the lens of community health systems, with a particular focus on the contextual factors and mechanisms influencing their effectiveness.

Methods: The study builds on three qualitative sub-studies resulting in four articles, each examining different aspects of sexual and reproductive health and rights programmes for adolescents and young people aged 10 to 24 years. Sub-study I analysed discourses on youth sexuality and sexual health through photo-elicitation interviews and focus group discussions with 25 participants. Sub-study II explored the perceptions and roles of 14 community-based health workers in addressing sexual and reproductive health and rights challenges among adolescents in Zambia, employing Charmaz’s grounded theory approach. Sub-study III used a realist evaluation approach to develop programme theories for short-term sexual and reproductive health and rights programmes and the national comprehensive sexuality education (CSE) programme, drawing on data from key informant interviews and realist-informed workshops with stakeholders, teachers, and adolescents across 32 schools. Thematic analysis, guided by realist evaluation principles, was applied to Sub-study III.

Results: In Sub-study I, three interpretative repertoires were constructed: ‘sex is for mature people’, where adolescents viewed themselves as too young for sex; ‘gendered (dis)respective behaviour’, highlighting how gender strongly influenced perceptions of respect related to sexuality, particularly for girls; and ‘acquiring and using knowledge’, in which young people struggled between possessing SRHR knowledge and applying it. These repertoires form dominant discourses in Zambia that shape how adolescents and young people construct their sexuality and interact with sexual and reproductive health and rights programmes.In Sub-study II, community-based health workers were found to play dual roles as both grandmothers and professionals. We introduce the core category ‘being both a grandmother and a community-based health worker’, which builds on four sub-categories: ‘being educators on sexual and reproductive health’, ‘being service providers and links to sexual and reproductive health and rights services’, ‘being advocates for adolescents’ sexual and reproductive health and rights’, and ‘reporting sexual violence’. These workers navigated their dual roles by blending community responsibilities with professional duties, although this duality sometimes resulted in challenges and tensions. In some cases, they managed these difficulties by exercising discretion. Sub-study III developed programme theories for both short-term and long-term SRHR initiatives. The short-term theory envisioned an ideal scenario where supportive policies, socio-cultural norms, and existing health structures enabled interventions to trigger mechanisms such as improved awareness, communication, and social connections. For the long-term CSE programme, the mechanisms identified included autonomy, curiosity, fear of the negative consequences of sex, and ‘juggling’ – the ability to navigate contextual conditions and conflicting mechanisms. All of these mechanisms significantly shaped how AYP engaged with, adopted, or benefited from the programme.

Conclusion: This study underscores the critical role of normative discourses in shaping adolescents’ and young people’s experiences of their sexuality. Effective SRHR programmes, including CSE, require a deep understanding of these discourses alongside robust monitoring and evaluation systems to identify gaps, track progress, and inform future interventions. The programme theories discussed in this thesis can serve as a foundation for these efforts, helping to activate productive mechanisms and minimise harmful ones in specific contexts. These recommendations aim to foster a supportive environment that ensures equitable access to sexual and reproductive health and rights information and services for adolescents and young people.

Introduction: Many adolescents in low- and middle-income countries face challenges related to sexual and reproductive health and rights, which are exacerbated by gender inequalities. One approach to address these issues is the integration of Comprehensive Sexuality Education (CSE) in schools. However, the process of effectively implementing CSE in these settings is often suboptimal. There is a significant lack of research exploring the specific conditions and methods that effectively lead to enhanced knowledge and improved decision-making in sexuality and gender equality among adolescents through CSE. This realist evaluation protocol will address this gap by exploring how the nature and pattern through which CSE is provided has a) changed adolescents’ knowledge regarding sexuality and gender relations and b) shaped adolescents’ capacity to make positive decisions.

Methods: This study uses a multiple-case design, combining realist evaluation with participatory action research methods to explore Comprehensive Sexuality Education (CSE) integration across multiple levels in Eastern province—from provincial to community levels. Data collection will occur in phases, utilizing interviews, photovoice, drawings, reviews, and observations. The study involves several key steps: 1) identifying challenges to CSE integration, 2) creating an initial theory or action plan that explains how CSE promotes positive decisions among adolescents about sexuality, 3) testing this theory through case studies, and 4) refining the theory and formulating recommendations to improve future CSE integration. Additionally, the study will document informal, contextual, and horizontal factors (ICAMO configurations) that influence the integration of CSE at the school level and affect adolescents' understanding and decision-making regarding sexuality and gender relations.

Discussion: This study will contribute to the development of strategies for effectively facilitating the integration process of similar programmes within the school system. The study will further contribute to methodological development in participatory research driven realist evaluation.

Introduction: Many adolescents in low- and middle-income countries face challenges related to sexual and reproductive health and rights, which are exacerbated by gender inequalities. One approach to address these issues is the integration of Comprehensive Sexuality Education (CSE) in schools. However, the process of effectively implementing CSE in these settings is often suboptimal. There is a significant lack of research exploring the specific conditions and methods that effectively lead to enhanced knowledge and improved decision-making in sexuality and gender equality among adolescents through CSE. This realist evaluation protocol will address this gap by exploring how the nature and pattern through which CSE is provided has a) changed adolescents’ knowledge regarding sexuality and gender relations and b) shaped adolescents’ capacity to make positive decisions.

Methods: This study uses a multiple-case design, combining realist evaluation with participatory action research methods to explore Comprehensive Sexuality Education (CSE) integration across multiple levels in Eastern province—from provincial to community levels. Data collection will occur in phases, utilizing interviews, photovoice, drawings, reviews, and observations. The study involves several key steps: 1) identifying challenges to CSE integration, 2) creating an initial theory or action plan that explains how CSE promotes positive decisions among adolescents about sexuality, 3) testing this theory through case studies, and 4) refining the theory and formulating recommendations to improve future CSE integration. Additionally, the study will document informal, contextual, and horizontal factors (ICAMO configurations) that influence the integration of CSE at the school level and affect adolescents' understanding and decision-making regarding sexuality and gender relations.

Discussion: This study will contribute to the development of strategies for effectively facilitating the integration process of similar programmes within the school system. The study will further contribute to methodological development in participatory research driven realist evaluation.

Introducción: Muchos adolescentes de países de ingresos bajos y medios se enfrentan a retos relacionados con la salud y los derechos sexuales y reproductivos, que se ven exacerbados por las desigualdades de género. Un enfoque para abordar estos problemas es la integración de la Educación Sexual Integral (ESI) en las escuelas. Sin embargo, el proceso de implementación efectiva de la ESI en estos entornos no suele ser óptimo. Hay una falta significativa de investigación que explore las condiciones y métodos específicos que conducen efectivamente a un mayor conocimiento y una mejor toma de decisiones en sexualidad e igualdad de género entre los adolescentes a través de la ESI. Este protocolo de evaluación realista abordará esta carencia explorando cómo la naturaleza y el patrón a través de los cuales se proporciona la ESI han a) cambiado el conocimiento de los adolescentes con respecto a la sexualidad y las relaciones de género y b) moldeado la capacidad de los adolescentes para tomar decisiones positivas.

Métodos: Este estudio utiliza un diseño de casos múltiples, combinando la evaluación realista con métodos de investigación-acción participativa para explorar la integración de la Educación Sexual Integral (ESI) a través de múltiples niveles en la provincia Oriental, desde el nivel provincial hasta el comunitario. La recopilación de datos se realizará por fases, utilizando entrevistas, fotovoz, dibujos, revisiones y observaciones. El estudio consta de varios pasos clave 1) identificar los retos para la integración de la ESI, 2) crear una teoría inicial o plan de acción que explique cómo la ESI promueve decisiones positivas entre los adolescentes sobre la sexualidad, 3) probar esta teoría a través de estudios de casos, y 4) refinar la teoría y formular recomendaciones para mejorar la futura integración de la ESI. Además, el estudio documentará los factores informales, contextuales y horizontales (configuraciones ICAMO) que influyen en la integración de la ESI a nivel escolar y afectan a la comprensión y la toma de decisiones de los adolescentes respecto a la sexualidad y las relaciones de género.

Discusión: Este estudio contribuirá al desarrollo de estrategias para facilitar eficazmente el proceso de integración de programas similares dentro del sistema escolar. El estudio contribuirá además al desarrollo metodológico de la evaluación realista impulsada por la investigación participativa. 

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.

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.

Building on the value of engaging with and enabling the participation of marginalised young people in research, theaim of this article was to profle practical and procedural issues faced when conducting studies with young peoplewho experience some form of marginalisation. Drawing on observations and research experiences from four diversecase studies involving young people who were either imprisoned in Cambodia, living in informal urban communitiesin North India, residing in rural northern Sweden or attending school in rural Zambia, learnings were identifed underthree thematic areas. Firstly, a need exists to develop trusting relationships with stakeholders, and especially the participating young people, through multiple interactions. Secondly, the value of research methods that are creative andcontext sensitive are required to make the process equitable and meaningful for young people. Thirdly, it is importantto fatten power relations between adults and young people, researchers and the researched, to maximise participation. These fndings can inform future youth research in the feld of global public health by detailing opportunitiesand challenges of engaging in research with young people on the margins to promote their participation.

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not).

Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda.

Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives.

Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

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.

Although the outcomes of comprehensive sexuality education are generally promising and positive, there has been limited research on how and under what conditions these outcomes are achieved. This article analyses the contextual factors and underpinning mechanisms that influence the implementation and outcomes of comprehensive sexuality education. Using the realist evaluation approach, data collection and analysis were conducted concurrently, beginning with an existing programme theory, followed by a literature review and then primary data collection through four realist workshops with 50 stakeholders and 60 learners. Thematic analysis, informed by the realist evaluation of demi-regularities, identified three key demi-regularities centred on the mechanisms of autonomy, curiosity, fear and juggling. These are the ‘autonomy to make the right decision’, ‘curiosity to learn and explore adolescents’ sexuality’, and the ‘role of fear in adolescents and young people’s sexual health education’. The study highlights that while comprehensive sexuality education seeks to empower learners, this empowerment is often selectively applied – particularly in more contentious areas like condom and contraception use, topics related to abortion and sexual and gender minorities – due to broader societal and cultural influences. To realise the benefits of comprehensive sexuality education to the full, a more inclusive and culturally sensitive approach is necessary that enables adolescents and young people to explore all aspects of sexual and reproductive health and rights and make informed decisions without undue pressure or fear.