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Community based interventions for strengthening adolescent sexual reproductive health and rights in Zambia

Research project The overall purpose of this project is to identify the mechanisms that trigger integration of SRHR interventions into community based health systems and whether such integration promotes (or not) acceptability and adoption of SRHR services.

Neglect of sexual and reproductive health and rights (SRHR) for adolescents results in poor health outcomes such as unwanted pregnancies, sexually transmitted infections, and violence. Community-based interventions aimed at strengthening SRHR for adolescents can help to reduce such health challenges. There is limited knowledge of the mechanisms that can effectively deliver such interventions, or of the processes that can bring about their integration into the health system. The purpose of this project is to identify the mechanisms that facilitate integration of SRHR interventions into community health systems, and establish whether such integration promotes (or not) the acceptability and adoption of SRHR services. This will be achieved by conducting a multiple case study embedded within an ongoing RCT. A theory-driven evaluation will be applied, which will, through a stepwise approach, develop and refine a causal theory resulting in policy recommendations, steering further research and informing teaching programmes. The 3-year project was conceived based in the partners´ mutual interest in health policy and systems research with a focus on community-based interventions to promote equity and the right to health. We aim for a long-term partnership through mutual development of methodological expertise and projects beyond this ResearchLink proposal. Regular workshops, study visits, and virtual meetings for senior and junior researchers will form the backbone of activities.

Project overview

Project period

2017-01-01 2019-12-31

External funding

Vetenskapsrådet, 2017-2019: SEK 1,200,000

Research subject

Reproduktiv hälsa, Folkhälsovetenskap

Project description

Purpose and aim

Adolescents have distinct health care needs from those of adults, particularly in the area of sexual and reproductive health and rights (SRHR). Neglect of their specific health needs leads to negative outcomes such as unwanted pregnancies, sexually transmitted infections and sexual violence. Community based interventions aimed at strengthening SRHR among adolescents can help to reduce such health challenges.ii;iii It has long been established that for health services to be beneficial for the young population they should be adolescent-friendly, that is; accessible, acceptable, equitable, appropriate and effective for different youth subpopulations, as defined by the WHO.iv For SRHR interventions to be successful they moreover need to be compatible with the community context and health system structure, that is; they need to be well integrated. A key question for such interventions is therefore: how can they can be integrated and sustained in the local community- and health structures? The overall purpose of this project is to identify the mechanisms that trigger integration of SRHR interventions into community based health systems and whether such integration promotes (or not) acceptability and adoption of SRHR services. This ResearchLink project is embedded in a randomized control trial (RCT) “Research Initiative to Support the Empowerment of Girls (RISE)"- which aims to reduce adolescent girl pregnancies and marriages by increasing knowledge in Sexual and Reproductive Health (SRH), uptake of contraception, and safer sex practices through the payment of girls’ school fees and the promotion of adolescent friendly SRH services at community level in Zambia. The community health system in Zambia consists of health centers/health posts and community actors including Community Based Health Workers (CBHWs) and local leaders. The ResearchLink project will enhance the capacity of the Department of Public Health, University of Zambia (UNZA) and Unit of Epidemiology and Global Health (EpiGH), Umeå University (Sweden) in health policy and systems research through a collaborative partnership. In Zambia, the Department of Public Health has been implementing and evaluating interventions aimed at promoting maternal, neonatal and child health for more than 10 years with the view of contributing towards strengthening health systems responses to the SRH needs of marginalized groups. At Umeå university, EpiGH has during the last decade developed its expertise in health policy and systems research with a focus on community based interventions. In addition the ResearchLink will benefit from the relationship with University of Bergen (UiB) in Norway and other institutions.

A. Research aims

1. To understand how, why and under which conditions the integration of SRHR interventions into community health systems will lead to (or not) acceptability and adoption of SRHR services by analyzing:
- the nature and pattern through which SRH services provided by the Community Based Health Workers (CBHWs) have changed.
-community's perspectives of the changes in terms of acceptability and adoption (includes accessibility) of SRH services provided by the CBHWs and at the health post / health centre.
This will be achieved by 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention aimed to strengthen adolescent SRHR into the community health system lead to adolescent friendly services within the community health system; 2) refining the causal theory through case studies; 3) identifying context conditions and mechanisms underlying effective integration of a community based SRHR intervention and 4) finally propose a refined causal theory and set of recommendations to guide policy makers, steer further research and inform teaching programmes.

B. Aims for capacity building and collaboration

The project further aims to:
- identify conceptual approaches and methodologies for exploring the integration of a community intervention for strengthening adolescent SRHR into the community health systems
- build individual and institutional capacity for strengthening the evaluation and implementation of a community intervention for strengthening adolescent SRHR.

Survey of the field

Interventions aimed at strengthening adolescent SRHR in low and middle income countries

Every year, approximately 7.3 million girls below age 18 give birth in LMICs while about 10 million girls are married with 46% of these being in sub-Saharan Africa. There are substantial risks associated with adolescent pregnancy such as complications of childbearing, unsafe abortions, maternal and neonatal mortality and morbidity as well as violence and sexually transmitted infections. Early pregnancy and marriage is also associated with school dropout. Low education may expose young women to health risks including sexual risk taking. Women with lower education status may have low health literacy and underutilise family planning services.
Community based interventions aimed at providing SRH information and services can help to reduce SRH health challenges associated with adolescent pregnancies and marriages. Interventions for reducing adolescent pregnancy, marriage and school dropout have mainly focused on providing SRH education and economic support particularly at primary school level. Focusing specifically on SRH education, positive outcomes were for example recorded in an HIV education program in primary schools in Kenya where compared to the control arm, the intervention sites had 28% lower pregnancy rates. Other interventions have been less successful; for example, the Zimbabwe microcredit program for young women did not effectively meet its overall goals of empowering the SRH capacity of young women. Similarly an SRH intervention in Malawi did not manage to increase condom use. In Tanzania the impact of interventions on girls and young women’s agency and household gender dynamics was questionable.
Integration of intervention to the community health system: a missing piece for success?
It has been argued that while some countries have taken steps towards integrating SRH services into the community health system, the pace of the integration progress has been generally slow and little consensus exists about the optimal models of integration or about how best to achieve them, with the consequence that the term means different things to different stakeholders and takes a diversity of forms". This problem has been compounded by limited knowledge of the mechanisms for delivering these SRH interventions, including the integration process and how to sustain changes triggered by the interventions. There have thus been increased calls for further research for mechanisms and contextual factors that support integration and sustainability of such interventions. A growing body of international guidance on the scaling up and sustainable implementation of community based health interventions, such as interventions to strengthen adolescent SRHR, recognises the contribution of both the formal health sector and community factors to the success of programmes . In most circumstances, community-based health interventions are “caught between the formal health system and the community and often in a “grey zone” between public, non-governmental and private health systems”. To enhance the success of such interventions, it is important to promote better integration of community based health interventions into formal and community aspects of the health systems. The formal part includes health system delivery, human resource for health, the supply chain and governance systems. On the community side, key factors to consider include the community's capacity to engage and participate in the implementation process, commit and sustain health actions and ensure development of effective partnerships between a complex array of actors involved in the intervention. It is thus the combination of the formal health systems and community aspects that make the community health system.
Fostering the integration of an intervention into the community health systems is “both relational and complex” due to a plural set of providers, diverse norms, values as well as less formal and horizontal mechanisms which shape coordination, accountability, health practice and health seeking behaviour at community level. Atun et al provide a systematic conceptual framework for researching or analyzing the integration of interventions into health systems which will be relevant to our project. According to this framework, examining the integration process requires examining the nature of the problem being addressed (e.g. pregnancies and early marriages), the intervention (.i.e. the RISE community component package), the adoption system (e.g. community, schools, health facilities), the health system characteristics (i.e. Community Based Health Workers (CBHWs), SRH services), and the broader context (sociocultural factors, programme implementers, regulations).

Project description and mode of cooperation

Zambia profile and adolescent sexual and reproductive health
Zambia, a country located in the southern part of Africa is a lower middle income country. About 60% of the population is below the international poverty line. Almost 53% of the total 14 million inhabitants are under the age of 18 years. The country faces several health systems challenges. 31% of 20-24 year olds are married before age 18. In addition, 25% of married girls aged 15-19 have an unmet need for family planning. About 30% of girls aged 15 to 19 years begin child bearing, 8% have experienced sexual violence and the HIV prevalence among youths aged 15-24 is 7%. The maternal mortality ratio is still high at 398/100, 000 live births and about 30% of the mortality is as result of abortions of which 80% of these are among adolescents.

Community health system in Zambia

The formal health system in Zambia consists of five levels of service delivery. The highest level is 3rdLevel Hospitals, followed by 2ndLevel Hospitals and 1stLevel Referral Hospitals. Health centres (HCs) and health posts (HPs), which make up the highest proportion of health facilities in Zambia, are located at the lowest levels of service delivery in communities. The HCs and HPs collaborate with community- based health workers (CBHWs) such as Community Health Workers (CHWs)/ Community Health Assistants (CHAs) and Neighbourhood Health Committees (NHCs) in delivering and monitoring health services (including SRH services) in the communities. The CBHWs are conceived as “members of communities who work either for pay or as volunteers in association with the local health care system and usually share ethnicity, language, socio-economic status and life experiences with the community members they serve.

Compared to CHWs, whose training is short and not standardized, CHAs are expected to undergo a year’s standardized training programme. There are about 23,500 CHWs and 1000 CHAs in Zambia. Health posts serve small communities with populations of approximately 5001000 households in the rural areas. It is this combination of the HCs/ HPs and community actors such CHAs/CHWs and structures such as NHCs which make up the community health system. The community component of RISE which uses schools and communities as the arenas for implementation (described below) will involve CHAs/ CHWs as coordinators in order to initiate integration of the intervention into the community based health system.

The RISE intervention

The Research Initiative to Support the Empowerment of Girls (RISE) is a randomized controlled trial funded by the Research Council of Norway (25 million NOK) being implemented by UNZA and the University of Bergen (UiB) from 2015 to 2020 in 150 school. The trial enrolls girls who are in grade 7 (average age approximately 15 years), and supports them for 2 years (grades 8 and 9). The trial aims to test interventions for enhancing opportunities for communities to support adolescent girls to continue going to school and increase girls’ possibilities to postpone pregnancy and marriage. The RISE intervention has three arms.;1) the control arm (30 schools) which provides limited school material (books and pens) support 2) the economic arm (60 schools) which supports packages paying school fees, monthly limited financial support to girls and annual financial support to families 3) the community component (60 schools) and where the ResearchLink proposal is embedded. The community component includes (1) community and parent meetings promoting supportive social norms around postponement of early marriage and early childbearing as well as promoting education for girls and; 2) establishment of new clubs or strengthening of existing youth clubs in order to increase knowledge of SRH including modern contraceptives, and change behavioural and control beliefs relating to contraceptive use among in- and out-of school adolescent girls and boys. The SRH education will be delivered at youth clubs twice per month in the school. The community meetings will be held three times per year in each cluster or school. The clubs are open to girls participating in the trial (in and out of school) and boys who attend the same grades as these girls. The clubs and community dialogues will be coordinated by teachers and CHAs/ CHWs who will work with youth peer educators. These coordinators will undergo an intensive training on comprehensive SRHR which will be provided by the UNZA. A Comprehensive Adolescent Reproductive Health and Life Skills Curriculum developed by the RISE Research based on the review of several international curricula will be used to guide lessons in the youth clubs. Films or role plays presenting the key messages will be used to start discussions in community and youth club meetings.

What does the ResearchLink project add to RISE?

This ResearchLink project focuses on analyzing the integration of the RISE community based intervention for strengthening SRHR into the community based health system in Zambia. The ResearchLink projects adds an evaluation component which is currently not comprehensively captured by the RCT which will include the evaluation of final outcomes of childbearing, marriage and schooling, as well as a process evaluation on quality of the delivery of lessons in the youth clubs and facilitation of community meetings, experiences with the various intervention components, and perspectives on the accessibility of SRH services. Thus the ResearchLink project will add value to the RISE intervention by unfolding the mechanisms of integration which trigger (or not) the strengthening of SRHR at community level. Such information is essential in understanding some of the differences in achievements in the different contexts/ clusters in the community component as well as serving the implementation of community based SRHR interventions beyond the RISE intervention.

Methodological framework- Theory driven evaluation: an appropriate methodology for evaluating complex interventions

The methodological framework we have chosen for the project is theory driven evaluation, which we suggest is the most appropriate for evaluating innovations in community health systems- whose implementation involves multiple actors and organizations who operate in distinct administrative environments and multiple layers of hierarchy. This research project aligns with health policy- and systems research’s aim to produce new knowledge to improve how societies organize themselves to achieve health goals. Realist evaluation is a type of theorydriven evaluation that aims to ascertain why, how, and under which circumstances programs succeed or fail. It is based on the work of Pawson and Tilley and focuses on how the mechanisms of change are triggered by the intervention and contextual factors that lead to observed outcomes.

Realist evaluation seeks to provide results that can be acted upon by decision makers. Realist evaluation begins with the formulation of the theory behind the development of an intervention, known as the programme theory. The programme theory is understood as every day, prosaic theories that explain how social problems are generated and how interventions can help to solve then. The programme theory is best considered as a hypothesis that can be tested, and that forms the basis for empirical testing in case studies. Usually are programme theories not explicitly stated when interventions are developed, and consequently the evaluators have to formulate the programme theory based on previous research and/or on knowledge and experiences of stakeholders involved in the intervention design. The programme theory is afterwards tested through observation of real cases where the intervention has been implemented. The programme theory connects context (C), mechanisms (M), and outcomes (O) – creating potential CMO configurations. The application of CMO configurations should result in a set of ‘context-mechanism-outcome’ (CMO) statements: “In this context, that particular mechanism fired for these actors, generating those outcomes. In that context, this other mechanism fired, generating these different outcomes.” A critical element in realist evaluation is that of mechanisms. Mechanisms intermediate between the concrete components of the interventions and the outcomes. According to Pawson and Tilley a mechanism is “not a variable but an account of the behaviour and interrelationships of the processes that are responsible for the change”. Elucidating mechanisms has shown to be a useful way to bridge the gap between theory building and practical recommendations; xxvii if we are able to identify the mechanisms that lead to positive change, they can guide scaling-up processes.
Data collected serves to refine the preliminary programme theory and specify a middle-range theory. A middle- range theory “lies between the minor but necessary working hypotheses … and the all-inclusive systematic efforts to develop a unified theory that will explain all the observed uniformities…” providing plausible explanations of why, how, and under what circumstances the intervention triggered mechanisms that led to certain outcomes. A theorydriven evaluation is methods-neutral but usually combines qualitative and quantitative methods for collecting data on context, mechanisms and outcomes.

Overall research strategy

Drawing on the methods proposed by van Belle et al we will follow a step-wise approach to the research. Through the collection and triangulation of data from different sources,-explanatory case studies (defined as the study of a phenomenon in its real-life context of the mechanisms in-context of strategies to strengthen SRHR at community level will be developed.

Step 1: Situating the intervention in the context The first step adopts a policy analysis approach in which existing relevant policies on SRH in Zambia and related literature and documentation will be collected and reviewed. Communication with stakeholders will also take place to discuss their understanding of the intervention and jointly agree on the scope of the evaluation.

Step 2: Eliciting the preliminary programme theory In this step we will develop the programme theory (or hypothesis) to be tested. The initial theory will guide the design on empirical case studies. Based on the discussions and reviews in steps 1, we will compile an initial programme theory of integration of the community based intervention for strengthening adolescent SRHR into the community based health systems. This will have two components as proposed by van Belle el al 1) an “action model” outlining the steps and pathways of intervention following a logic model format; 2) a “change model” outlining the developers’ assumptions about how the intervention will work e.g. through development of new systems, collaborative networks etc. This will form the basis for the development of a data collection plan, outlining the specific research aims, objectives, domains and data collection strategies.

Step 3 Testing the programme theory The third step consists of empirically testing the programme theory. Data collected in this step will serve to identify Context-Mechanism- Outcome patterns that provide an explanation for the observed outcomes. For the analysis the “retroduction” approach will be applied, whereby the observed outcomes are explained by looking into the mechanisms and context elements. This step serves to indicate whether the initial programme theory stands as relevant in the light of the empirical findings. We will test the initial programme theory through an in-depth study of the of the community component conducting a multiple case study. We aim to select approximately 4 cases. We shall define cases as the catchment areas of the health posts/ centre and corresponding schools (which can be defined as a unit of the community health system). The cases- will be selected on a theoretical replication argument, meaning that cases will be selected based on their potential to provide contrasting contexts and outcomes.

Step 4: Specification of middle range theory: How, why, for whom and under what circumstances does the innovation work? Step 4 uses the findings from previous steps to enhance the understanding of how, why, for whom and under what circumstances the intervention works. These are essential questions when moving into the scale-up of interventions. This step will begin concurrently with step 3 in cycles of reflection. It is anticipated that findings might also become part of action learning processes around specific components (e.g. capacity building of CBHWs, team work, work motivation, personal values). The phase will end after data collection is completed and case studies analyzed, and will result in a refined action model of strengthening integration of adolescent SRHR into the community based health systems that includes an account of “what worked for whom in the context of the communities in Zambia”.

Capacity building and collaboration

The activities will include workshops and study visits. The workshops and visits will focus on development of the realist evaluation project protocol, capacity building, designing and conducting in realist evaluation, data collection, writing case studies and scientific publications and grant writing.