Specifying implementation strategies used in delivering services for HIV, gender-based violence and sexual and reproductive health to adolescent girls and young women in community health systems in Zambia

Background Adolescent girls and young women (AGYW) in Zambia experience challenges including gender-based violence (GBV) and difficulty obtaining care for sexual and reproductive health (SRH) and treatment for HIV. Implementation strategies for delivering GBV, SRH and HIV services targeted to AGYW in community health systems (CHS) have not been fully specified. We sought to define and specify common implementation strategies being used in Zambia. Methods In a qualitative case study in 3 districts, we interviewed 29 key informants from government bodies, NGOs, and community leaders; we also conducted 23 in-depth interviews with AGYW aged between 10 and 24 years. Analysis of the data used thematic analysis based on the four CHS lenses (programmatic, relational, collective action, and critical lenses) and on the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. Results Implementation strategies identified under the programmatic lens were 1) changing infrastructure, which included increasing health facilities and delivering adolescent- and young people-friendly services; 2) training and educating stakeholders, which consisted of increasing capacity building, developing and using educational materials, ongoing training and educational outreach visits; and 3) adapting and tailoring services to context, which included delivering integrated services and developing by-laws. Relational lens strategies were 1) developing stakeholder interrelationships such as building a coalition of service providers; and 2) using new funding through cost-sharing among stakeholders. Under the collective action lens , implementers mainly engaged consumers, by increasing demand using community networks, using mass media to share information, and intervening with patients to enhance uptake of services. The critical lens showed that effective implementation of GBV, SRH and HIV services was affected by structural and socio- cultural factors such as social stigma and cultural norms. Conclusion This study builds on the ERIC compilation of implementation strategies by identifying and specifying implementation strategies used in the delivery of HIV, GBV and services for AGYW in community health systems. We provide additional evidence on the importance of relational and collective-action approaches in strengthening community-engaged implementation and dissemination.