Adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs), experience challenges that impact their health and well-being, including HIV, poor sexual and reproductive health (SRH), and gender-based violence (GBV) (1–4). Zambia is among the most affected countries in Africa (5). These public health concerns are interlinked in a complex cycle (5, 6), perpetuated by poverty, gender inequality, and social marginalization (5, 7). For instance, most HIV infections in the sub-Saharan region are associated with SRH-related issues such as pregnancy and sexually transmitted infections (5, 7). Violence and the threat of violence can compound HIV or SRH problems by undermining AGYW’s ability to negotiate equal decision-making within relationships, including safer sex practices (2, 7, 8).
AGYW in Zambia continue to experience several HIV, SRH, and GBV challenges (9). For instance, teenage pregnancy has been consistently high: 29.0% in the two most recent rounds of the Demogaphic and Health Surveys 2013–2014 and 2018 (10, 11). In 2021, 5.9% of young women and 1.8% of young men aged 20–24 years were living with HIV (12, 13). Further, young people in the 15–24 age cohort account for the lowest levels of viral load suppression: 80.5% of females and 81% of males (12, 13). Comprehensive knowledge of HIV remains low, at 40.5% of girls and 38.6% of boys aged 15–19 years (12, 13). Moreover, condom use at most recent sexual encounter is still low, at 36% for girls and 41% for boys (12, 13). Further, among AYP with an STI, only 45.0% were receiving treatment in 2021 and 2022 (12, 13). A substantial majority (61.3%) in 2021 and 58.0% in 2022) of adolescents aged 10 to 19 were diagnosed and treated for sexual and gender-based violence (SGBV) (13).
The Zambian Ministry of Health, through the 2015 National Guidelines for SRH, HIV and GBV services, is seeking to address these interrelated public health problems by implementing integrated prevention, management, and treatment strategies (2, 7, 14). Integrated service delivery is vital as it promotes satisfaction and potential gains in health outcomes by reducing the chance of missed opportunities through timely and convenient service delivery (2). Further, integration reduces HIV-related stigma and discrimination, duplication of activities, inefficiency of, and competition for scarce resources, thereby enhancing program effectiveness and efficiency (5, 6, 8, 15). To promote acceptability and sustainability of the integrated strategies, it is important to consider community health systems (CHS) in the implementation process (2, 7, 14). A CHS is defined as “the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health structures” (16). Evidence suggests that LMICs that have invested in CHS have recorded some positive public health gains (17, 18). CHS have attracted increased interest because of their potential to leverage diverse community resources and advance population well-being (4, 14, 19–21). The gains are partly due to the ability of CHS to widen participation and collective action and promote trust in health services (20, 22). Investment in CHS is also important because HIV, GBV, and SRH problems are often “caught between the formal health system and the community and often in a “grey zone” between public, non-governmental and private health systems” (23).
CHS can be viewed through the programmatic, relational, collective action, and critical lenses (24, 25). The four lenses are used to approach, understand, and dissect or evaluate CHS. The programmatic lens entails looking ‘into CHS’ as the site of formal programming (design) (24, 25). It is concerned with health systems building blocks such as human resources, financing, technologies, and infrastructure (24, 25). The relational lens shifts the focus from the what (design) of programmes to the how (implementation). It views the CHS as a ‘peopled’ system of relationships – formal or informal. It focuses on multiple interactions and feedback loops, interests and expressions of power among the actors that together constitute a social system (24, 25). The collective action lens is concerned with mechanisms and processes that enable actors in the CHS to mobilize, collaborate, and act collectively in identifying, prioritizing, and owning solutions to health problems (24, 25). The critical lens examines CHS issues from a political-economy perspective, including what lies behind programmes and how to decolonize programmes or make them contextually relevant (24, 25). CHS thinking is useful in accounting for actions and processes often overlooked in the delivery of health services (24, 25).
Meanwhile, implementation strategies being applied in CHS that are necessary for quality implementation of HIV, GBV, and SRH services have been inconsistently described in many LMICs (17, 26, 27). Implementation strategies can be defined as “methods or techniques used to enhance the adoption, acceptability, and sustainability of a clinical program or public health services” (26). The Expert Recommendations for Implementing Change (ERIC) study aimed to refine a published compilation of strategies that can be used in isolation or in combination in implementation research and practice (28). However, Powell et al (28) called for better contextualising of the ERIC implementation strategies in various settings, as the strategies could be more applicable in clinical settings in the US or North America, given the focus of the ERIC project and the composition of the expert panel that developed the strategies.
For HIV, GBV, and SRH services, these strategies include community sensitization, gender empowerment, adolescent- and youth-friendly health services, and HIV testing (14, 29). Comprehensively documenting and specifying implementation strategies can provide lessons on how the strategies facilitate realizing public health benefits in the CHS (26), including promoting the uptake of health services (26, 30, 31). Further, such evidence can contribute toward promoting penetration and sustainability of services by promoting community participation in delivering public health services (9, 17, 27, 30, 32). This study aimed to contribute toward addressing this knowledge gap by exploring strategies used in the implementation of HIV, GBV, and SRH services for AGYW in community health systems in Zambia.