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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.