Characteristics of participants
A total of 41 HSPs were recruited in this study. A total of 29 nurses/nurse aides, eight EHPs, and four doctors dealing with ASH-related issues participated in this study. More females participated as compared to males (30:11 respectively). The characteristics of the participants are presented in Table 1.
There was a total of five superordinate themes that emerged from interrogating the data obtained from the participants. A total of 19 subordinate themes were then obtained from the five superordinate themes, and the summary of findings is presented in Table 2.
Overview of adolescent sexual health issues
One of the superordinate themes that arose from the findings was the general overview of adolescent sexual health trends in the two districts. Under this superordinate theme, four subordinate themes emerged and are discussed in-depth in the section that follows:
Prevalence of STIs
The prevalence of STIs in the districts was reported to be going up. Participants felt that adolescents in these two districts generally had feeble health-seeking behaviours. Participants further cited that adolescents now engage in sexual activities early and with older people risking suffering from STIs. It was also reported that most females are more at risk from STIs than male adolescents as they are usually targeted by an older man who would have been through a lot in terms of sexual engagement.
“We have observed a steep rise in the STI prevalence, particularly in female adolescents. The biggest challenge is that these adolescents have poor health-seeking behaviours as they seldom come to these facilities; only when they are now severely ill would they turn up for treatment”. Participant 10, Female (48 years).
“Very young adolescents are now presenting at the health facility suffering from STIs. The biggest challenge is that adolescents now engage in sexual activities at an early age. They date individuals who are way older than them, particularly the girls. These cross-generational sexual activities have been the major contributing factor to the high prevalence of STIs that we are observing”. Participant 11, Female (42 years).
“These adolescents that we treat here when they go back to the community and feel better, they throw away the medication we would have given them even though they have not completely healed, and they continue spreading it, resulting in this high prevalence of STIs”. Participant 1, Female (52 years).
Prevalence of pregnancies
One of the subordinate themes that came up under this superordinate theme was that there are very high teenage pregnancies as several adolescents are forced to drop out of school. The HSPs felt that most pregnancies happen during the Christmas holidays when the cross-border workers, popularly known as injiva will be back for the festive holidays. Participants further cited that these injiva would be having a disposable income that there can use to lure and coerce the adolescents, particularly the females, into having sexual relations with them over those holidays. However, participants further pointed out that many illegal gold miners (popularly known as amakorokoza in the local communities) entice these adolescents into having some sexual relations with them.
One participant said:
“We have failed as health service providers to curb adolescent pregnancies as they go berserk during the festive holidays when they are coerced by the injivas who would have saved up to come to enjoy holidays back at home. Bearing in mind that the rural setup is different from townships, adolescents have their huts which would be sometimes far from the parents' huts meaning they could sneak out easily and go and have sexual intercourse without anyone noticing”. Participant 28, Male (35 years).
Sexual health-related complications
Participants felt that due to adolescents’ poor health-seeking behaviours and the issue of seeking treatment late, they have some complications regarding STIs left untreated for a very long time and had to refer the adolescents to Central Hospitals outside the districts for specialised care. Adolescents have also had complications during delivery as some of their pregnancies would have been discovered very late by their parents.
“One of the adolescents went for circumcision, he came after he was culturally circumcised, and he was not healing. When we attended to him, he disclosed that he had had an STI for months and was discharging a lot of pus. After we enquired why he did not present to the health facilities earlier, he said he was afraid his parents would discover as they are not allowed to sleep with women before they were circumcised. The condition worsened after circumcision, and he had to be brought to the facility. We referred the case to Mpilo Central Hospital”. Participant 10, Female (48 years).
“Let me give you an experienced that shocked me. There was this adolescent girl who came with her parents complaining of stomach cramps. The parents did not know the adolescent was pregnant, only to be told when they brought her that she was in labour. The unfortunate part was that the baby was a breach, so we had to refer them to a central hospital. It was unfortunate that both the adolescent and the baby did not make it”. Participant 11, Female (42 years).
Participants, particularly from the Nyamandlovu area in Umguza, cited that most homesteads are mannered by adolescents as their parents and guardians migrate to South Africa and Botswana in search of opportunities to be able to fend for their families. Most adolescents are forced into sex by poverty as they try to make ends meet. However, the majority do not make much, and sometimes they cannot fully support their adolescents, leading to them engaging in sexual intercourse with older people to get basics from those people though predisposing themselves to STIs and pregnancies.
“Due to financial challenges here in the rural areas, most breadwinners head to South Africa or Botswana in search of jobs to fend for their families, leaving their adolescents behind. If you realise that most are not sending any monies home because of this lockdown caused by COVID 19. How do you think these adolescents survive? Some end up dating older men and women to get favours”. Participant 25, Female (22 years).
“Adolescents struggle if they are left alone by their caregivers as they do not have a proper family structure to support them. Therefore, if they are now household heads, homestead now becomes a venue for other adolescents who live with parents to engage in sexual activities. Most parents are driven to migrate to other towns and even other countries searching for opportunities to make a living and fend for their adolescents”. Participant 4, Female (58 years).
Role of MHS in ASH issues
Four subordinate themes emerged under the superordinate theme “Role of MHSs in ASH issues.” These are described in depth in the sections that follow.
Education and awareness campaigns
The key participants were involved in educating the general populace, including adolescents, on SH related issues to foster safer sexual practices in the communities. Participants further cited that they even get invited to schools, churches, and community gatherings to disseminate SH’s information to improve sexual health outcomes. Participants also noted that in partnership with different Non-Governmental Organisations (NGOs) dealing with sexual health issues, they develop flyers, training material and help ensure that the distribution processes are as effective as possible.
“We are involved in education and awareness campaigns where we develop teaching material and ensure we go to schools, churches, and any community gatherings through invitation or voluntarily and disseminate information regarding adolescent sexual health-related issues.” Participant 14, Male (43 years).
“We work with different stakeholders, including NGOs, as I have said that our duty is centred on health promotion through prevention. We develop flyers, education material and deliver education and awareness sessions to promote safer sexual practices in adolescents. Therefore, we have to ensure we reach out to most adolescents and equip them with knowledge”. Participant 26, Male (38 years).
Provision of contraceptive products
It emerged that several participants, particularly the Nurses, Nurse Aides, and Doctors, were involved in the distribution/insertion of contraceptive products. After adolescents have been educated about their services, they access these services with an informed mindset. It, therefore, emerged that several participants played a significant role in the provision of these services.
One Participant said
“We provide contraceptives to women, including these adolescents, as well as male condoms for male adolescents as well. We usually advertise our services during the awareness campaigns so that those adolescents who decide to engage in sexual activities do so in a manner that reduces the chances of being infected as well as reduce the chances of them having unwanted pregnancies, which lead to unplanned responsibilities and resulting in high rates of school dropouts”. Participant 20, Female (27 years).
Treatment of STIs
One subtheme that emerged under the role of these critical stakeholders was that they were involved in the treatment of STIs and providing support to those infected with HIV and AIDS through different programs and the provision of anti-retroviral therapy (ART). Participants cited that adolescents usually come to the clinics to seek treatment, although most of the time they come when the infections are at advanced stages due to some barriers. Participants also cited that they also encourage those that they treat to bring their partners to reduce reinfection.
“We have been involved in the treatment of STIs over and above other roles, such as the provision of contraceptives. However, we face challenges that these adolescents come when infections are already at an advanced stage”. Participant 10, Female (48 years).
“We treat STIs and provide support services for those that are living with HIV and AIDS and also do contact tracing and encourage adolescents to bring their partners for treatment as well to minimise chances of reinfection”. Participant 18, Female (47 years).
Performing and supervising births
It emerged that a significant proportion of adolescents come to the facilities to deliver. However, the majority are referred to Central hospitals as they are deemed at high risk. Participants cited that most of the adolescents come to the facilities already at advanced stages of labour. Participants, therefore, noted that though it is encouraged that these adolescents deliver in central health facilities with adequate infrastructure and human resources to deal with potential complications, the majority deliver in their clinics sometimes due to other factors such as transport challenges.
“We supervise several adolescents giving birth though normally they are expected to be attended to in Central hospitals with the capacity to deal with complications. However, most times, these adolescents come at an advanced stage of labour with some even delivering on their way to the clinics”. Participant 34, Female (42 years).
“We are generally not expected to supervise births by adolescents as they are expected to be attended to in the higher hierarchy of our health facilities. Considering that we are in deep rural areas, there are many challenges that we face that hinder us from referring these adolescents to either district hospitals or central hospitals outside our districts, one of such being transport”. Participant 40, Male (36 years).
Performing medical male circumcision
It also emerged that Health service providers are involved in circumcising adolescents at clinics, with some facilities partnering with NGOs to ensure that this service is available to fight against the spread of HIV and AIDS.
One participant said:
“We are partnering with some NGOs to provide circumcision though our numbers are deficient. We are 5 months into the program, and we are failing to reach the intended targets as most of the adolescents prefer to go and get circumcised culturally”. Participant 3, Male (33 years).
A total of six subordinate themes arose to denote challenges that are faced by the MHS and its HSPs in managing ASH related issues. These are discussed in-depth below:
Shortage of resources
Participants cited that different stakeholders are usually invited to participate in health awareness campaigns, particularly by the schools. However, HSPs mentioned that they are very short-staffed in clinics and very much overwhelmed and fail to respond positively to these invitations, which present an opportunity to engage with adolescents in a comfortable environment.
“We usually receive invitations from schools to go and engage with adolescents or participate in awareness campaigns. We seldom go as we are very short-staffed in these clinics; for example, in this clinic, we are only two (nurses), so you can imagine that if I leave my colleague alone, how much workload would she have?” Participant 3, Male (33 years).
“We would have hoped to do more than we are currently doing. However, we rarely have adequate resources to cover most of the adolescents’ needs except when an NGO comes and implements a project; then, we become part of it. Usually, if that NGO pulls out after their funding is exhausted, we cannot sustain the programs”. Participant 30, Female (45 years).
“I am expected to cover two wards that amount to about 40 square kilometres to conduct awareness campaigns and do contact tracing. My motorbike broke down two years ago, and it is in a state of disrepair, as you can see there. I cannot consistently walk these 40 square kilometres; therefore, we normally do what is in our power”. Participant 41 Male (43 years).
Poor health-seeking behaviour
One of the subordinate themes that came up under challenges was that most adolescents that belong to very cultural families have deplorable health-seeking behaviour. Participants cited that they usually delay seeking treatment until it is too late to be rushed to health facilities.
“We usually conduct health education on those that would have come to the clinics with the hope that they will share the information with their peers. The biggest challenge, however, is that they usually come to the clinics when they are very ill; for example, when they are being circumcised there during their cultural initiation ceremonies in the bush, women are not allowed to go there, so we are not able to go there, the adolescent would be brought to the clinic when they see that the person is now dying”. Participant 41 Male (43 years).
“The majority of the cultures, particularly the Xhosa here, who are predominant in Ntabazinduna, rarely seek services from the clinics. They first go to the Traditional Healers and would only bring the adolescent after they would have failed of which majority of the times it would be late and a lot of damage has already been done”. Participant 10, Female (48 years).
“Those that have their STIs treated by the Traditional Healers some do not heal completely, and they spread that STI or they suffer severe consequences later on”. Participant 11, Female (42 years).
Inadequacy in the training of staff to handle adolescents
Participants cited they felt a gap in terms of the knowledge and capacity to address adolescents’ issues fully. Participants felt that gap had hindered their ability to successfully lure adolescents to health facilities to seek services or even information. They felt they lack the necessary skills to deal effectively with adolescents, which has lowered the demand for their programs.
“We rarely undergo training on how to deal with adolescents. They are a sensitive age group, and we need to understand how to handle them fully. We have read many developments in the field of sexual health and adolescents; it is quite challenging to keep up without being trained”. Participant 6, Female (42 years).
“In some institutions, they have dedicated Health personnel that deal with adolescent sexual health issues. However, here we are, a jack of all trades. It will have been great if some are trained to cope with the adolescents' sexual health needs”. Participant 10, Female (48 years).
“Adolescents are very delicate and need to be accommodated as they are at a stage where they are trying to discover who they are. We need to be trained on how we deal with them to foster behaviour change and adoption of safe practices”. Participant 41, Male (43 years).
Non-availability of adolescent-friendly and private facilities
Participants cited that one of the significant challenges they encountered in the discharge of their duties was the lack of youth-friendly infrastructure in the public facilities that accorded the youths enough privacy. Participants cited that adolescents value privacy as sometimes they would seek services without their parents or guardians’ knowledge. Participants, therefore, felt that there is a need for adoption of youth-friendly facilities, such as those offered in Harare where adolescents have dedicated private rooms at facilities and use back door entries that are barricaded from the general public maximum privacy and ensure they are comfortable.
“We feel our facilities are too public and do not accord adolescents the privacy that they require as they share facilities with the general populace. They are often judged if they seek contraceptive methods leading them to shun away from the facilities”. Participant 10, Female (48 years).
“Let us bear in mind that adolescents usually need maximum privacy if they seek sexual health services. They are typically judged harshly by the community if they are seen seeking sexual services and engaging in sexual activities. The majority would not want their guardians, parents, and elders to see them in clinics seeking sexual health services”. Participant 11, Female (42 years).
“We are not well equipped to lure adolescents into utilising our facilities leading to them engaging in unsafe sexual activities. Our facilities do not have privacy as adolescents queue together with the general populace to consult on sexual health-related issues leading to stigmatisation and judgment. In the capital city, we have special clinics for adolescents; for instance, the Mbare clinic that deals with ASH related issues. In some clinics in Epworth, they have private rooms for adolescents, and they do not use the same entrances as the general populace. We seriously need to invest very much in such strategies to ensure uptake of our programs and improve SH outcomes of adolescents”. Participant 30, Female (28 years).
Promiscuous behaviours by adolescents
Another subordinate theme that emerged was that adolescents exhibit promiscuous behaviours and engage in sexual activities early and with multiple partners. This becomes a challenge as they are hard to control, and at the end of the day, predispose themselves to infections and unplanned and unwanted pregnancies.
“These kids rush into having sexual intercourse with the majority starting from the 12 years of age, which is now common in this district. The worrying issue is that they have multiple partners and brag about it as if it is fashionable. I normally ask myself whether it is this technology that they are exposed to or not”. Participant 2, Female (50 years).
“The majority of our adolescents no longer get to 20 years without children. By that age, there would be mothers or fathers of two to children on average. They no longer go through the stages of puberty properly and fully mature. They would have been parents already; that is why we have a significant proportion of these adolescents dropping out of school”. Participant 41, Male (43 years).
“Most of these cultural initiations incite the adolescents to engage in early sexual activities as they feel they would have been given the right of passage, and they think and feel they are ready to engage in sexual activities. Most of them end up having multiple partners”. Participant 40, Male (36 years).
Hostility of HSPs towards adolescents
It emerged that some of the health service providers have a hostile attitude towards members seeking health services, including adolescents who become intimidated. Participants cited that some members do not uphold values with isolated cases where HSPs have been reported to have physically or emotionally abused their clients. Furthermore, participants mentioned that they now give as minimum effort as possible as most are generally disgruntled with the working conditions and remuneration of their services obtaining in the country.
“A long time ago, we usually thought nursing was a calling, and most individuals were not driven by the financial benefits associated with the job. I think we were confused as one needs the money and makes ends meet if they are productive. Due to the economic situation obtaining in the country, people do not work that much or do not commit themselves that much and sometimes become hostile even to the patients”. Participant 38, Female (32 years).
“You realise that the government told us to work for 2 days a week as they are not able to pay as well? However, in rural areas, we are expected to work 6 days a week, yet our counterparts work for 2 days a week, and the other 5 days, they look for employment to augment their income. Do you think we would apply ourselves that much and treat the patients fairly, yet there is that inequity?” Participant 10, Female (48 years).
Indigenous health system factors that could be factored into modern health systems
Two subordinate themes emerged under this superordinate theme. These are discussed in-depth in the sections below.
Another theme that emerged as an essential factor that needs to be considered for adoption from the IHS is how they mobilise and get adolescents to be circumcised. Participants cited that they are facing challenges in obtaining the required numbers and meeting the targets. Participants felt that working with the IHS in the male circumcision program would ensure that they ensure the targets are met and provide the circumcision procedures done safely and effectively, whether culturally or through health facilities.
One participant said:
“Culturally, the communities perform circumcision on the adolescents, of which that one of the strategies is we are recently trying to implement in our clinics as funded by the NGOs, and we have failed to get the numbers. When you compare with the initiation gatherings conducted in the communities, they can mobilise the numbers and ensure more adolescents are circumcised. However, we are not fully in support of how it is done. We can, therefore, team up as stakeholders and supervise these circumcisions using standardised and safe methods”. Participant 11, Female (42 years).
It emerged from the data that one of the factors incorporated into the MHSs is Ubuntu’s issue (treating patients with humanity). Participants cited that Ubuntu’s element in the MHSs has seriously been degraded due to prevailing contextual settings where HSPs are overwhelmed, poorly remunerated, and demotivated. Participants further highlight that Ubuntu’s element is still valued in the IHS as those that run it strive to maintain their reputation and lure as many clients as possible.
“Even if their way of operation is not standardised (having exact dosages), and in some cases, us having to deal with the damage that would be done. To clarify this, sometimes, their patients are given overdoses of sexual stimulants. However, the system has its weaknesses; it is premised on Ubuntu's spirit where one is not denied treatment because they do not have adequate resources to pay. In some cases, payments are even made later in life after one has healed completely and has had the opportunity to look for money. It contrasts with our MHS where payment is usually demanded upfront for most services save for only a few services”. Participant 22, Male (29 years).
“Our trade (nursing) is no longer a calling. We are also struggling like everybody else because most of us have lost Ubuntu's spirit, and we are no longer going the extra mile to serve these adolescents. This is different from the IHS, where one must maintain Ubuntu's element because that brings the clients home. We still need that element in our systems to dignify our work and command the respect of the public”. Participant 38, Female (32 years).
Strategies to foster the integration of IHS and MHS
Two subordinate themes came up on how they could integrate the IHS and MHS.
Engagement between stakeholders
Participants felt a need for continued engagement between the IHS and MHS through workshops as both systems serve a significant chunk of the population. Participants cited that the relations are the majority of times sour as there are competing values and interests and actors in one system view the other as a competitor that is incompetent that just takes clientele unnecessarily.
“One thing that you need to understand is that I have vast experience in the two systems as I am a Nurse now though my father is a Traditional Healer. This has made me see things differently and appreciate that there is room for collaborative effort rather than working in parallel. I understand that from my experience, I managed to convince my father to seek treatment for a condition that had bedevilled him for years. Still, because of his strong beliefs in his abilities to heal himself, he did not consider modern health systems as an option. I believe we have not done much to engage our indigenous health system counterparts except when there is something wrong, and it culminates to a blame game”. Participant 31 Female (39 Years).
"We once organised a workshop with the indigenous health system personnel at some point as we realised that during their adolescent circumcision period, majority of those culturally circumcised adolescents had infections, lost a lot of blood, and some even died. After the engagement, we deployed health personnel in these initiation ceremonies to monitor the process. However, we had only to send health personnel belonging to that culture. Therefore, with continuous engagement, there is a possibility of overcoming the odds and foster this integration”. Participant 41, Male (43 years).
Community cultural gatherings
Participants cited a need to utilise the cultural gatherings to foster and forge a good relationship between the IHS and the MHS. Participants noted that in these gatherings, most information is shared, for instance, the Umguyo ceremony performed by Amaxhosa to initiate male adolescents. Participants felt information sharing and sharing of values in such gatherings could also be used as a platform for collaboration.
“The majority of health service providers are divorced and distance themselves from events that are going on in these communities as most do not belong to the districts. This creates segregation as there is no trust and collegiality between the key stakeholders in the communities and the HSPs. This stifles programs that we want to implement in these communities”. Participant 9, Male (28 years).
“With me, I feel integrated into the community as I grew up here and from this district. However, most of my colleagues find it difficult to fit in the societies as they do not mix and mingle with the community workers. The community also sees them as in a different class, thereby hindering collaborative efforts. A good starting point is to be involved in these community activities and adopts them as a platform for dialogue and information sharing”. Participant 12 Female (22 years).