Department of Public Health, School of Medicine, University of Zambia, School of Public Health, P.O. Box 50110, Lusaka, Zambia.
Department of Global Health and Epidemiology, Umeå University, 90185, Umeå, SE, Sweden.
Reprod Health. 2019 Aug 13;16(1):122. doi: 10.1186/s12978-019-0788-4.
Although large scale public sector community health worker programs have been key in providing sexual and reproductive health (SRH) services in low- and middle-income countries, their integration process into community health systems is not well understood. This study aimed to identify the conditions and strategies through which Community Health Assistants (CHAs) gained entry and acceptability into community health systems to provide SRH services to youth in Zambia. The country's CHA program was launched in 2010.
A phenomenological design was conducted in Nyimba district. All nine CHAs deployed in Nyimba district were interviewed in-depth on their experiences of navigating the introduction of SRH services for youth in community settings, and the data obtained analyzed thematically.
In delivering SRH services targeting youth, CHAs worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders. CHAs delivered SRH education and services in health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and they also worked to build relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. CHAs used their existing social networks to deliver SRH services to adolescents. By embedding the provision of information about SRH into general life skills at community level, the topic's sensitivity was reduced and its acceptability was enhanced. Further, support from community leaders towards CHA-driven services promoted the legitimacy of providing SRH for youth. Factors limiting the acceptability of CHA services included the taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.
Strengthening CHAs' ability to negotiate and navigate and gain acceptability in the community health system as they deliver SRH, requires support from both the formal health system and community networks. Limitations to the acceptability of CHA-driven SRH services are a product of challenges both in the community and in the formal health system.
尽管大规模的公共部门社区卫生工作者计划在中低收入国家提供性健康和生殖健康（SRH）服务方面发挥了关键作用，但它们融入社区卫生系统的过程尚不清楚。本研究旨在确定社区卫生助理员（CHA）进入和被社区卫生系统接受以向赞比亚青年提供 SRH 服务的条件和策略。该国的 CHA 计划于 2010 年启动。
在尼扬巴区进行了现象学设计。对在尼扬巴区部署的所有 9 名 CHA 进行了深入访谈，了解他们在社区环境中为青年提供 SRH 服务的引入经验，对所获得的数据进行了主题分析。
在为青年提供 SRH 服务方面，CHAs 与一系列社区行为者合作，包括其他卫生工作者、安全孕产行动小组、社区卫生工作者、邻里卫生委员会、教师以及政治、传统和宗教领袖。CHAs 在卫生机构、学校、警察局、家庭环境和社区空间提供 SRH 教育和服务。他们利用自己在卫生机构提供服务的角色获得信任并进入社区，还通过定期举行联席会议以及充当志愿卫生工作者和卫生部之间的经纪人，与其他社区一级行为者建立关系。CHAs 利用他们现有的社交网络为青少年提供 SRH 服务。通过将 SRH 信息纳入社区一级的一般生活技能中，降低了该主题的敏感性，提高了其可接受性。此外，社区领导人对 CHA 驱动服务的支持促进了为青年提供 SRH 的合法性。限制 CHA 服务可接受性的因素包括讨论性问题的禁忌、性别歧视环境、与其他提供者的竞争以及进行家访的挑战。
为 CHA 提供 SRH 时，加强他们在社区卫生系统中进行协商和获得认可的能力，需要得到正式卫生系统和社区网络的支持。CHA 驱动的 SRH 服务的可接受性受到社区和正式卫生系统中挑战的限制。
