Umeå University's logo

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.

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.

Background: In 2014, the Zambian government introduced the Comprehensive Sexuality Education (CSE) framework, decentralising its implementation from the national to the provincial administration. The provincial structures of the Ministries of Health and Education play an important role in providing technical, policy direction and coordination support. However, little research has focused on the role of CSE collaboration at the provincial level.

Objectives: This study sought to explore multisectoral collaboration dynamics influencing the implementation of the CSE framework at the provincial level in Zambia. Methods: This qualitative study involved 29 interviews with diverse stakeholders at the provincial level such as government departments (health, education, etc.), private sector, religious and traditional leaders involved in CSE implementation. We used reflexive thematic analysis, guided by an integrative collaborative governance framework.

Results: The findings were grouped under collaboration dynamics domains: principled engagement, shared motivation, and capacity for joint action. Barriers to principled engagement included provincial structures and their mandate, exclusion or sidelining of certain actors, inadequate financial transparency, and weak formal relations. Shared motivation included collective understanding of the purpose, a supportive policy environment and consensus in adapting the CSE framework. Capacity for joint action efforts included collaborative training of teachers, joint monitoring, and collaborative to address SRHR challenges.

Conclusion: This study highlights challenges limiting meaningful engagement, exclusion of some actors, financial constraints, and weak coordination, which hinder collaboration. There is need for enhancing provincial leadership capacity to effectively coordinate stakeholders through enforcement of transparent resource management, collective planning, implementation and monitoring for effective CSE delivery.

Background: Community health systems (CHS) for the implementation of comprehensive sexuality education (CSE) are a critical strategy for promoting adolescent sexual and reproductive health and rights (SRHR). Despite their importance, there is limited evidence on how these systems contribute to the delivery of adolescent-responsive CSE and SRHR services. This study explores collaborative CHS pathways and factors influencing their role in CSE implementation in rural districts of Zambia.

Methods: We conducted a qualitative study involving 21 purposively selected stakeholders from government departments (health, education, and police), non-governmental organisations, and community actors. The community actors included school representatives, peer educators, parent–teacher association members, and traditional and religious leaders. All interviews were transcribed verbatim, checked for accuracy, and analysed in NVivo (version1) using reflexive thematic analysis.

Findings: Four key themes emerged: school-based collaboration in the delivery of CSE, healthsector collaboration in SRHR service delivery, community involvement in promoting or addressing SRHR challenges, and collaboration with legal and policy environment enforcement. CHS collaborative efforts contributed to increased SRHR sensitisation in communities, improved adolescent referrals to SRHR services, and strengthened community support for addressing child abuse, adolescent pregnancies, and early marriages, thereby enhancing uptake of health services. However, weak collaboration with parents and traditional leaders contributed to resistance, largely due to prevailing social norms around CSE and SRHR.

Conclusion: The study highlights the critical role of collaborative CHS in improving CSE implementation in rural Zambia. Effective collaboration across schools, communities, the health sector, and legal frameworks contributes significantly to promoting CSE and addressing SRHR-related challenges. However, cultural resistance, stemming from limited collaboration, hinders implementation. Strengthening collaborative mechanisms is essential to foster community ownership and acceptability, which are critical for improving the delivery of CSE and SRHR services among adolescents.