Charity Nyambe

O3 PLUS PROJECT RESEARCH REPORT ZAMBIA FEBRUARY 2024 1 CONTENTS 1….......................................................... Acronyms 2 ……………………………………….. Acknowledgments 2 ….…………………………………….. Executive Summary of Findings 3 ….…………………………………….. Introduction and Background 4 ….…………………………………….. Approach and Methodology 5 ….…………………………………….. Literature Review 6 ….…………………………………….. Research Findings 7 ….…………………………………….. Recommendations and Conclusions 8 ….……………………………………... References 2 Acronyms The table below shows a summary of acronyms that are used in this report. SRHR Sexual Reproductive Health Rights CBU Copperbelt University TVTC Technical and Vocational Teachers College AGYWs Adolescent Girls and Young Women UNESCO United Nations Educational Scientific and Cultural Organization ART Anti-Retroviral Treatment 3 Acknowledgments. We extend our heartfelt appreciation to the University of Zambia, Lusaka Business and Technical College, Evelyn Hone College, Chalimbana University, Kwame Nkrumah University, Kabwe Institute of Technology, Nkumbi International College, Northern Technical College, Copperbelt University, Mukuba University, as well as Technical and Vocational Teachers College for their invaluable support and cooperation throughout the research process. We are grateful for the dedication and assistance provided by the personnel from the Ministry of Education and Ministry of Health, whose insights and guidance greatly enriched our study. Additionally, we extend our thanks to the health facilities visited for their hospitality and cooperation. We would also like to express our gratitude to UNESCO Office Zambia for their support and encouragement. Their contributions have been essential to the successful completion of this research project. 4 Executive Summary of Findings The study delved into the sexual and reproductive health and rights (SRHR) landscape among adolescents and young people in tertiary institutions in Zambia, with a focus on family planning and post-abortion services. Findings revealed significant gaps in access to SRHR services, particularly concerning family planning and post-abortion care, attributed to limited availability, stigma, and socio-cultural barriers. Disparities in the availability and accessibility of HIV and SRHR services across tertiary institutions were evident, exacerbated by inadequate infrastructure and limited awareness among students. While young women demonstrated a moderate level of knowledge regarding reproductive health and contraception, misconceptions and gaps in understanding sexual and reproductive rights were apparent, highlighting the need for comprehensive education and awareness programs. Attitudes towards sexual and reproductive health varied among young women, influenced by socio-cultural norms and religious beliefs, with prevalent stigma surrounding abortion and contraception hindering access to essential services. Policy and programming recommendations include targeted interventions such as comprehensive SRHR education programs, capacity building for service providers, and policy reforms to improve access to family planning and post-abortion care services. These findings underscore the importance of holistic approaches to address the multifaceted challenges facing adolescents and young people in accessing SRHR services in tertiary institutions, aiming to ensure their sexual and reproductive well-being. 5 1. Introduction and Background Adolescents and young people aged 10–24 years represent a significant portion of the Zambian population, comprising about one-third of the demographic. Despite their numerical presence, this group encounters numerous challenges in accessing sexual reproductive health (SRH) services. Particularly concerning, is the disproportionate impact on adolescent girls and young women aged 15–24 years, who face poorer sexual and reproductive health outcomes compared to their male counterparts (Knowledge and Use of Sexual Reproductive Health and HIV Services, 2021). Recognizing the urgency of addressing these disparities, the "Mapping and Evaluating Access to Sexual and Reproductive Health Services in Tertiary Institutions in Zambia " study was undertaken. The study aimed to identify and address gaps in access to SRH services for adolescents and young people in Zambia, while also exploring opportunities for strengthening service delivery. By shedding light on these issues, this study seeks to inform policies and interventions aimed at improving the sexual and reproductive health outcomes of adolescents and young people in tertiary institutions across the country. Following this, the findings of this report will reveal the thoughts, ideas and suggestions of stakeholders such as: Ministry of Education; Ministry of Health, University Administrations, Health Care Workers, and Students. During the course of the research, eleven (11) universities within Zambia were surveyed, namely; University of Zambia, Lusaka Business and Technical College, Evelyn Hone College, Chalimbana University, Kwame Nkrumah University, Kabwe Institute of Technology, Nkumbi International College, Northern Technical College, Copperbelt University, Mukuba University, as well as Technical and Vocational Teachers College. The eleven universities were surveyed together with their respective health facilities. The research delved deep into understanding the knowledge and access of SRHR services by students aged between 18 and 24 years old. In order to get a clear understanding of the impact of the study, mixed methods of research were employed (qualitative and quantitative), through administration of structured questionnaires, focus group discussions, key informant interviews and In-depth interviews targeting; Students, Dean of students, Health Care Workers, Ministry of Education and Health Adolescent Health Officers, O3 Plus peer educators as well as UNESCO Programs Officer. 6 2. Approach and Methodology The research employs a multifaceted approach, utilizing a mixed-methods methodology to ensure comprehensive data collection and analysis. This approach seamlessly blends quantitative and qualitative methods, allowing for the triangulation of results to enhance data quality. Drawing from best practices in reproductive health research (Bryman, 2016), the study recognizes the diverse identities of young women in tertiary institutions and their influence on decision-making, thus emphasizing intersectionality as a foundational aspect of the methodology. Furthermore, the engagement of young men is deemed crucial, given their potential influence on the attitudes and behaviours of young women regarding sexual and reproductive health and rights (SRHR). Through the use of various research methods and approaches such as literature review, structured questionnaires, open-ended interviews, and focus group discussions, the methodology seeks to provide a holistic understanding of knowledge, attitudes, practices, and experiences related to SRHR among young people. The online survey tool served as a vital component of data collection, facilitating the participation of both male and female students aged between 18 and 24 years. This survey provided valuable insights into students' existing knowledge and understanding of SRHR, as well as their access to related services. In addition to the online survey, focus group discussions were conducted to allow students to share their ideas and propose solutions to challenges encountered in accessing SRHR services within their communities and institutions. Similarly, Focus Group Discussions (FGDs) were instrumental in understanding the impact of the project, enabling a deeper exploration of students' knowledge and perceptions of SRHR. Furthermore, one-on-one interviews were conducted with health workers, lecturers, and university management personnel using structured questionnaires. These interviews shed light on the role of institutions in ensuring equal access to SRHR services for students, highlighting existing challenges and potential solutions from the perspective of health providers and educators. Overall, this comprehensive approach and methodology enable the study to gather rich and nuanced data, which can inform evidence-based policies, programs, and strategies aimed at addressing barriers to accessing SRHR services and promoting reproductive health rights among young people in tertiary institutions. 7 3. Literature Review The literature review for this study explores existing research and scholarly works related to sexual reproductive health and rights (SRHR) among adolescent’s young people in tertiary institutions. The review aims to provide a comprehensive understanding of the current knowledge, attitudes, practices, and challenges surrounding SRHR services in this demographic. 3.1 Access to SRHR Services Numerous studies have highlighted the importance of access to comprehensive SRHR services for adolescents and young people in tertiary institutions (Hall et al., 2019; Okumu et al., 2020). Accessible and youth-friendly services are essential for addressing the diverse needs of this population, including family planning, HIV prevention, post-abortion care, and sexual and genderbased violence (SGBV) support. 3.2 Knowledge and Awareness Research indicates varying levels of knowledge and awareness of SRHR among adolescents and young people in tertiary institutions (Chipeta et al., 2018; Chandra-Mouli et al., 2019). While some studies report high levels of awareness, others highlight gaps in understanding key concepts such as contraception, sexual rights, and gender-based violence. 3.3Attitudes and Behaviours Studies have explored the attitudes and behaviours of adolescents and young people towards SRHR issues, revealing complex socio-cultural dynamics (Marston et al., 2019; Mbeba et al., 2021). Factors such as stigma, cultural norms, and peer influence play significant roles in shaping attitudes towards contraception, abortion, and sexual activity. 3.4 Barriers to Access Several barriers hinder adolescents and young people’s access to SRHR services in tertiary institutions, including stigma, confidentiality concerns, high cost, low commodity, and lack of information (Ezer et al., 2017; Nanda et al., 2020). Structural barriers such as institutional policies and regulations also impact service provision and utilization. 3.5 Role of Institutions The role of tertiary institutions in promoting SRHR among students has been widely studied (Nalwadda et al., 2018; Izugbara et al., 2021). Institutions can play a crucial role in providing youth8 friendly services, implementing life skills and health education, as well as addressing gender-based violence on campus. 3.6 Intersectionality and Gender Dynamics Intersectionality theory underscores the importance of considering multiple identities and intersecting social factors in understanding SRHR issues among adolescents and young people (Crenshaw, 1991). Gender dynamics, socio-economic status, and cultural backgrounds influence access to and utilization of SRHR services. 3.7 Policy and Programming Policy and programming interventions are essential for addressing SRHR challenges among adolescents and young people in tertiary institutions (Hindin et al., 2019; Igras et al., 2020). Comprehensive sexuality education (Life skills and Health Education), youth-friendly services, and gender-sensitive policies are crucial components of effective SRHR interventions. Overall, the literature underscores the significance of addressing SRHR issues among adolescents and young people in tertiary institutions through a comprehensive and rights-based approach. By understanding the complexities and challenges surrounding SRHR services, policymakers, educators, and healthcare providers can develop evidence-based interventions to promote the sexual and reproductive well-being of adolescents and young people in tertiary settings. 9 4. Research Findings 4.1 Copperbelt Province Data Collected Institution FDGs Questionnaires KIIs Student 1:1 Health Facilities Mukuba 5 77 3 4 4 8 211 3 6 2 7 94 3 8 2 5 160 2 3 1 University Copperbelt University Luanshya TVTC NORTEC 4.2 Central Province Data Collected Institution FDGs Questionnaires KIIs Student 1:1 Health Facilities Kwame 5 141 3 2 2 2 24 3 3 1 Nkrumah University Nkumbi International College Kabwe Institute 10 of Technology 2 52 3 4 2 4.3 Lusaka Province Data Collected Institution FDGs Questionnaires KIIs Student 1:1 Health Facilities The University 2 332 2 4 2 2 2 1 2 4 1 2 2 2 of Zambia Evelyn Hone 108 College 1 Lusaka 1 Business 46 and Technical Collage Chalimbana 194 University 1 4.4 Stakeholder Consultation Data Collected Institution Ministry KIIs of 1 Education Ministry of Health 1 UNESCO 1 11 4.5 Findings from Focus Group Discussions The research design incorporated focus group discussions, with each session accommodating between 5 to 10 participants. Across all eleven universities, participants engaged in sharing their perspectives and experiences concerning adolescent sexual reproductive health within their respective institutions. Insights gleaned from these discussions revealed a positive reception among students towards their involvement in the 03 plus program. Participants expressed appreciation for the program's effectiveness in imparting comprehensive HIV and sexual reproductive health knowledge and skills to peer educators. These trained peer educators have subsequently been disseminating vital information to their fellow students, contributing to increased awareness and understanding within the university community. Evident from these discussions, participants emphasized the availability of various sexual and reproductive health (SRH) services at the health facilities. These included HIV testing and counselling, HIV treatment, psychosocial support, family planning, condom distribution, STI screening, SGBV services and post-abortion care services. In citing specific examples, participants from focus group discussions shared unique perspectives such as below: a) At Evelyn Hone College, there is a concerning trend among female students involving the misuse of the morning-after pill, often obtained through unofficial channels within the student community. The stigma surrounding pregnancy among female students is notably stronger than that associated with a positive HIV status, contributing to a rise in unsafe abortions. Moreover, instances of judgmental attitudes from healthcare workers at the institutional clinic have been reported. In response, with the support of the 03 Plus cluster coordinator and the lecturer overseeing student welfare, a survey was conducted among students to assess the validity of these concerns. The survey findings prompted action from the college administration, leading to a meeting between college management and healthcare workers at the facility. As a result, efforts have been made to improve the attitudes of healthcare workers towards students, fostering a more supportive environment within the institution. b) At the University of Zambia, the 03 Plus project has facilitated the creation of an online platform that operates 24/7, offering students access to comprehensive sexual reproductive health information. Furthermore, a physical youth platform called the Global Platform has been established, providing students with a space for engaging in discussions about sexual reproductive health among peers. 12 4.6 Challenges In consolidating the information gathered from students at all the eleven institutions, it must be noted that during various interactions with students, including focus group discussions and one-on-one interviews, several key challenges regarding sexual and reproductive health rights (SRHR) emerged. Firstly, it was evident that many students lacked proper information on SRHR topics, with some unable to freely discuss them and others lacking confidence in the information they possessed. Secondly, fear and shame deterred some students from accessing SRHR services, driven by concerns about judgment from peers, healthcare providers, and partners. Additionally, shyness hindered students from seeking SRHR services directly from health facilities, leading some to rely on pharmacies or trusted individuals for assistance. Inadequate resources and commodities, particularly safe abortion and post-abortion care services, were highlighted as significant challenges at several universities. Interestingly, while male students demonstrated openness in discussing SRHR issues, a smaller percentage of female students felt similarly comfortable. The absence of student medical insurance or schemes further hindered access to SRHR services, as students were discouraged by the financial burden. Youth-friendly corners faced challenges due to the lack of conducive spaces, although efforts were being made to improve the situation at certain institutions. The presence of well-trained healthcare providers from diverse backgrounds was seen as crucial for creating inclusive and accessible healthcare environments. Moreover, misconceptions and gaps in understanding were prevalent among students, particularly regarding family planning, unsafe abortions, mental health, and gender-based violence. Addressing these challenges is imperative for ensuring the comprehensive and equitable provision of SRHR services to students in tertiary institutions. 4.6 Key Informant Interview with Dean of Students The Deans of Students and the lecturers overseeing student welfare are well-informed about the objectives of the 03 Plus program. They have actively cultivated an enabling environment to facilitate the implementation of the 03 Plus program and other student welfare initiatives. Notably, the collaborative relationship between 03 Plus cluster coordinators and institutional management is evident, as institutions have allocated office space for cluster coordinators, demonstrating a supportive stance towards the program's objectives. 13 4.7 Stakeholder Consultations Key Informant Interview Highlighted below are the findings from the stakeholder consultations between Ministry of Education, Ministry of Health and UNESCO during the key informant interview: Contextual Analysis of Existing SRHR Services What SRHR services are currently available in tertiary institutions in Zambia/ Zimbabwe? • Provision of SRH commodities and contraceptives • Counselling • Abortion • Family planning • Provision of information on SRH Are these services accessible to all students, including those from marginalised or underserved groups? Yes What are the key challenges or barriers in providing these services within the institutions? • Lack of commodities in health facilities • Lack of skilled and trained health care providers in youth friendly service • Negative attitude of health care providers • Social and cultural norms • Age of consent What policies and strategies exist to safeguard and guarantee the SRHR of young people in tertiary institutions? • National Adolescent Health Strategy which guides the provision of SRHR to young people in the country. • The Reproductive Health Policy Social Mapping of HIV and SRHR Services Is there a comprehensive list of HIV, and SRHR services available to youth in tertiary institutions in Zambia/Zimbabwe? • Yes What are the gaps in terms of HIV and SRHR services in these institutions? • Lack of skilled man power to provide youth friendly services Assessment of Reproductive Health Knowledge What are the specific areas where students demonstrate misconceptions or gaps in their understanding of reproductive health? 14 Policy and Programming Recommendations What specific policy changes or improvements in service provision would address the identified challenges and gaps in SRHR services within the tertiary institutions? • Training of more health providers in youth friendly services • Provision of SRH commodities What are the key components of a comprehensive program that would better serve the needs of young women in these institutions? • Training of more health providers in youth friendly services • Provision of SRH commodities How can services be made culturally sensitive and inclusive, addressing the diverse needs of students? • By training more health care providers in being youth friendly when dealing with you people 15 Recommendations and Conclusions Recommendations about effective provision of HIV and Sexual Reproductive Health Services to Adolescents and Young People in Tertiary Institutions. 1. Enhanced Information Dissemination: Implement comprehensive SRHR education programs targeting students to improve their knowledge and understanding of sexual and reproductive health rights. These programs should utilize various channels, including peer education, online platforms, and physical youth-friendly spaces, to ensure widespread dissemination of accurate information. 2. Addressing Stigma and Shame: Develop interventions aimed at reducing stigma and shame associated with accessing SRHR services. This may involve awareness campaigns, sensitization training for healthcare providers, and the promotion of non-judgmental attitudes within healthcare facilities. 3. Improving Access to Services: Address resource constraints and commodity shortages at health facilities by strengthening supply chains and increasing budget allocations for SRHR services. Additionally, explore options for implementing student medical insurance schemes to alleviate financial barriers to accessing healthcare services. 4. Creating Conducive Environments: Invest in creating youth-friendly corners and safe spaces within tertiary institutions to provide confidential and non-discriminatory SRHR services. Ensure these spaces are well-equipped and staffed with trained healthcare providers capable of handling diverse needs. 5. Diversifying Healthcare Providers: Encourage the recruitment and training of healthcare providers from key populations and marginalized communities to enhance diversity and inclusivity within healthcare settings. This would help address the specific needs of students from different backgrounds and identities. 16 Conclusion In conclusion, the study highlights numerous challenges and barriers to accessing sexual and reproductive health rights (SRHR) services among students in tertiary institutions. These challenges range from inadequate information and stigma to resource constraints and misconceptions. However, amidst these challenges, there are opportunities for improvement through targeted interventions and collaborative efforts. Efforts to enhance information dissemination, reduce stigma, and improve access to services can contribute to the overall well-being of students and promote a culture of sexual and reproductive health awareness within tertiary institutions. By addressing these challenges and implementing the recommended strategies, we can create more inclusive and supportive environments where students can access the SRHR services they need to thrive. 17 REFERENCES Bryman, A. (2016). Social research methods (5th ed.). Oxford University Press. Chipeta, E. K., Chimwaza-Manda, W., Kalilani-Phiri, L., Bauleni, A., & Bauleni, A. (2018). 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