Treading the thin line: pharmacy workers’ perspectives on medication abortion provision in Lusaka, Zambia

Context: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. Methods: We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. Results: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers’ motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion and level of desperation. Conclusion: These findings highlight how pharmacy staff informally determine women’s abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task-sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion

A case-study of OVC Case Management through the Zambia Family (ZAMFAM) project

Zambia’s HIV prevalence is estimated at 11% among adults aged 15–49 years and 1% among children younger than 15 years. An estimated 10% of Zambia’s population is at high risk of being orphaned or vulnerable due to the HIV epidemic. The Zambia Family (ZAMFAM) project aims to improve the care and resilience of vulnerable populations while supporting HIV epidemic control. ZAMFAM used a case management approach that tracks beneficiaries from identification to graduation. The Population Council conducted a qualitative case study to understand actors and perceptions, and document best practices. Program beneficiaries viewed the ZAMFAM program as having made a positive contribution to the lives of orphans and vulnerable children. Testimonials from beneficiaries reflect high knowledge of HIV prevention, care, and management and identify educational support as a benefit of the program. Home visitations were also hailed by beneficiaries and key stakeholders. As noted in this report, the perspectives of beneficiaries and stakeholders were sought in addition to a detailed review of key program documentation to identify best practices and lessons for future programming

Supporting Self-managed Abortion Care in “practice not premise”: Provider Perspectives, Roles, and Referral Pathways in India

Objective: Describe provider perspectives and roles in self-managed abortion (SMA) in India and identify referral pathways to facility- and self-managed abortion care. Methods: We conducted a qualitative study of 33 semi-structured interviews with a range of providers (medical, community health, and pharmacy) in India. We conducted a thematic analysis and identified referral pathways including the type of provider, the abortion care modality (in-facility or SMA), and the reason. Results: Referrals to facility-managed abortion care were common. Providers\u27 perception of SMA safety coupled with­ liability concerns resulted in discouraging clients from seeking SMA. Nonetheless, participants acknowledged three areas where providers played a role in SMA: providing information, dispensing medication, and providing support. SMA referrals pathways occurred bidirectionally between pharmacy workers and local providers. Some community health workers provided referrals to pharmacies, but more often only provided information and support. Conclusion: Despite provider concerns, support and referrals for SMA do occur in India. Understanding the dynamics of provider perspectives, roles, and referral pathways can inform improvements to comprehensive reproductive health policies and programs in order to promote client-centered abortion care—including SMA—and address provider concerns. There is a need for synergies between the formal health sector and SMA support networks. Keywords: Abortion, self-managed abortion, pharmacy, referrals, quality of car

“Burnt by the scorching sun”: Climate-induced livelihood transformations, reproductive health, and fertility trajectories in drought-affected communities of Zambia

Background: Climate-induced disruptions like drought can destabilize household and community livelihoods, particularly in low- and middle-income countries. This qualitative study explores the impact of severe and prolonged droughts on gendered livelihood transitions, women’s social and financial wellbeing, and sexual and reproductive health (SRH) outcomes in two Zambian provinces. Methods: In September 2020, in-depth interviews (n = 20) and focus group discussions (n = 16) with 165 adult women and men in five drought-affected districts, as well as key informant interviews (n = 16) with civic leaders and healthcare providers, were conducted. A team-based thematic analysis approach, guided by the Framework Method, was used to code transcript text segments, facilitating identification and interpretation of salient thematic patterns. Results: Across districts, participants emphasized the toll drought had taken on their livelihoods and communities, leaving farming households with reduced income and food, with many turning to alternative income sources. Female-headed households were perceived as particularly vulnerable to drought, as women’s breadwinning and caregiving responsibilities increased, especially in households where women’s partners out-migrated in search of employment prospects. As household incomes declined, women and girls’ vulnerabilities increased: young children increasingly entered the workforce, and young girls were married when families could not afford school fees and struggled to support them financially. With less income due to drought, many participants could not afford travel to health facilities or would resort to purchasing health commodities, including family planning, from private retail pharmacies when unavailable from government facilities. Most participants described changes in fertility intentions motivated by drought: women, in particular, expressed desires for smaller families, fearing drought would constrain their capacity to support larger families. While participants cited some ongoing activities in their communities to support climate change adaptation, most acknowledged current interventions were insufficient. Conclusions: Drought highlighted persistent and unaddressed vulnerabilities in women, increasing demand for health services while shrinking household resources to access those services. Policy solutions are proposed to mitigate drought-induced challenges meaningfully and sustainably, and foster climate resilience

Family support for adolescent girls and young women living with HIV in Zambia: Benefits, challenges, and recommendations for intervention development

Lack of family involvement is barrier to antiretroviral therapy adherence among adolescent girls and young women (AGYW). This study assessed family support for AGYW\u27s engagement along the HIV care continuum to inform the design of a family-focused intervention in Lusaka, Zambia. We conducted 16 in-depth interviews and four focus group discussions with 40 AGYW living with HIV. Three strategies were identified to strengthen family support. First, emotional and instrumental support are highly valued by AGYW and should be further developed or reinforced. Second, AGYW wanted more informational support and open discussion of HIV from family, and an intervention should aim to enhance these types of support. Third, existing appraisal support reinforced anticipated stigma among AGYW and discouraged disclosure, yet participants wished for more interactions with peers living with HIV. Appraisal support should therefore be reframed to help AGYW decide to whom they should disclose and how to do so safely

Perspectives of adolescent girls and young women on optimizing youth-friendly HIV and sexual and reproductive health care in Zambia

Youth-friendly health care delivery models are needed to address the complex health care needs of adolescent girls and young women (AGYW). The aim of this study is to explore the lived experiences of AGYW seeking comprehensive HIV and sexual and reproductive health (SRH) care and to elicit their preferences for integrated health care services. We conducted in-depth interviews and focus group discussions in Lusaka, Zambia among 69 AGYW aged 10-20 who were HIV-negative or of unknown status and 40 AGYW aged 16-24 living with HIV. The data were coded through deductive and inductive processes and analyzed thematically using modified World Health Organization (WHO) dimensions of quality for youth-friendly services. AGYW expressed preference for one-stop clinics with integrated services that could provide HIV services along with other services such as pregnancy testing and family planning. AGYW also wanted information on staying healthy and approaches to prevent disease which could be delivered in the community setting such as youth clubs. An integrated clinic should address important attributes to AGYW including short wait time, flexible opening hours, assurance of confidentiality and positive staff attitudes. Youth-friendly, integrated care delivery models that incorporate AGYW preferences may foster linkages to care and improve outcomes among vulnerable AGYW