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Background Child marriage has long been a public health concern around the world, because it has the potential to deprive adolescent girls of their sexual reproductive health rights and limits their ability to reach their full potential in life. The prevalence of child marriage has been consistently higher in sub-Saharan Africa than elsewhere. However, fewer studies have explored the influence of both individual and community-level influences on early marriage in sub-Saharan Africa. This study, therefore, examined individual and community-level factors associated with child marriages in Zambia. Methods Data came from the Zambia Demographic and Health Surveys (ZDHS) conducted in 2007, 2013–14 and 2018. A pooled weighted sample of 9990 women aged 20–29 years was used in the analysis. Stata software version 17 was used to perform statistical analysis, taking into account complex survey design. The association between individual- and community- level factors and early marital behavior was assessed using multilevel logistic regression models. Results The prevalence of child marriage among women aged 20–29 was 44.4 percent (95% CI: 42.1, 46.7) in 2018, declining from 51.5 percent (95% CI: 48.9, 54.0) in 2007. Women with secondary or higher level of education [aOR = 0.36, 95% CI = 0.26–0.49] and [aOR = 0.07, 95% CI = 0.03–0.18] and those whose age at first birth was (15–19 year) or (20–29 years) were associated with less likelihood of experiencing child marriage. Communities with a high percentage of women who gave birth at a young age [aOR = 1.36, 95% CI = 1.15–1.62] were more likely to experience child marriage. Individual and community-level characteristics accounted for 35% of the overall variations in communities' likelihood of experiencing early marriage. Even after controlling for both individual and community-level influences, the intra-class correlation revealed that around 4.5 percent of the overall variations remained unexplained. Conclusion Prevalence of child marriage has reduced over the years but is still high in Zambia. Both individual and community- level factors influenced child marriage in Zambia. There is a need to strengthen strategies that keep girls in school to delay their exposure to early sexual debut and child marriage. Designing of reproductive health interventions in the country should consider integration of community factors such as economic insecurity and access to reproductive health information.

Background Violence against women and girls is a major public health issue, a violation of human rights, and is linked to a number of harmful effects on one’s physical, mental, sexual, and reproductive health. Studies conducted in other parts of sub-Saharan Africa (SSA) suggest that there is an association between contextual factors and experience of intimate partner violence. However, in Zambia, this association is not well documented. Thus, this study was conducted to examine how individual and community-level characteristics influence spousal violence against women in Zambia. Methods Data from the most recent Zambia Demographic and Health Survey conducted in 2018 was used. A sample of 7,358 ever-married women aged 15–49 years was used in the analysis. Two level multilevel binary logistic regression models were employed to examine the association between individual and contextual-level factors and experience of spousal violence. Results The prevalence of spousal physical violence against women in Zambia was 21.1% [95% CI, 19.8, 22.5]. Women aged 15–19 [aOR = 2.36, 95% CI = 1.34–4.14] and 20–24 [aOR = 2.11, 95% CI = 1.38–3.22], who did not own mobile phone [aOR = 1.36, 95% CI = 1.10–1.69], and had low decision making autonomy [aOR = 1.24, 95% CI = 1.01–1.54] were more likely experience spousal physical violence. Furthermore, communities which had a low proportion of women with decision making power [aOR = 1.66, 95% CI = 1.26–2.19] were more likely experience spousal physical violence. Additionally, women whose partners’ drank alcohol [aOR = 2.81, 95% CI = 2.30–3.45] and those whose partners exhibited jealous behaviour [aOR = 2.38, 95% CI = 1.88–3.21] were more likely to experience spousal physical violence. Conclusion Both individual and community-level factors influenced spousal physical violence in Zambia. Integrating community level factors when designing interventions to address gender-based would be key to reduce women’s vulnerability to gender based violence in the country. There is need to re-evaluate and re-strategize current strategies being implemented to address gender based violence in the country to make them context specific.

Background Unintended pregnancies can pose significant public health concerns for both maternal and child health because of their associated risks and implications. Experience of unintended pregnancies may lead to delay in seeking antenatal care, thus leading to increased risk of complications during pregnancy and childbirth. Globally, the prevalence of unintended pregnancies has declined. However, the problem remains acute in sub-Saharan Africa. This study was conducted to examine the factors associated with an experience of unintended pregnancy among women of reproductive ages in Zambia. Methods This study used secondary data from the Zambia Demographic and Health Surveys (ZDHSs) which were conducted between 2001 and 2018. A pooled weighted sample of 4,090 pregnant women of reproductive age 15–49 years at the time of the survey was included in the analysis. Multivariable binary logistic regression model was employed to examine the association between independent correlates and experience of unintended pregnancy. All statistical analyses were conducted using Stata software. Results Findings show that the proportion of women of reproductive age who experienced unintended pregnancy in Zambia declined from 50.4% (95% CI: 47.1, 53.8) in 2001 to 45.2% (95% CI: 40.5, 49.9) in 2018. The decline in the prevalence of unintended pregnancy is more pronounced among women age groups 25–29 years and 30–34 years. Increasing age was associated with an increased risk of experiencing unintended pregnancies. On the other hand, women who were living in rural areas (aOR = 0.76; 95% CI: 0.58, 1.00) and those with tertiary education (aOR = 0.46; 95% CI: 0.26, 0.80) were less likely to experience an unintended pregnancy. Women who desired a large family (aOR = 0.45; 95% CI: 0.24, 0.85) and those who watched television (aOR = 0.75; 95% CI: 0.59, 0.94) had lower odds of experiencing unintended pregnancies. Conclusions The study has established that the prevalence of unintended pregnancy is still high in Zambia. Women’s age, place of residence, level of education, desired family size and exposure to media were associated with the risk of experiencing an unintended pregnancy. Enhancing access to family planning services and commodities targeting women with low education levels will be key to further reduce unintended pregnancies.

Background Modern contraception is one of the most significant public health interventions of the 20th century. This is because it improves maternal and child health. Despite the benefits, modern contraceptive use among adolescent girls and young women in Zambia remains low. Earlier studies in Zambia have ignored the influence of social context in understanding modern contraceptive use among adolescent girls and young women. Thus, this study was conducted to examine the individual and community level determinants of modern contraceptive use among adolescent girls and young women in Zambia. Methods Data from the nationally representative Zambia Demographic and Health Survey of 2018 were used in this study. A weighted sample of 3448 sexually active and non-fecund adolescent girls and young women (AGYW) aged 15–24 years was used in the analysis. The outcome variable for this study is modern contraceptive use. Modern contraceptive use was defined to include the following contraceptive methods captured in the demographic and health survey, female and male sterilization, oral contraceptive pills, intrauterine devices (IUDs), injectables, implants, male and female condoms and emergency contraception. Stata software version 14.2 Standard Edition was used to perform statistical analysis, considering complex survey design. Descriptive analysis and a multilevel binary logistic regression model was used to assess the determinants of modern contraceptive use among adolescent girls and young women. All analyses were weighted to account for under and over sampling in demographic and health survey. Results The prevalence of modern contraceptive use among adolescent girls and young women was (38.1% 95% CI: 35.9, 40.4). AGYW aged 20–24 were more likely to use modern contraceptive methods [aOR = 1.34, 95% CI = 1.12–1.59], as were AGYW who were married [aOR = 4.42, 95% CI = 3.70–5.20], with secondary education [aOR = 2.28, 95% CI = 1.43–3.63], those from Lusaka province [aOR = 1.46, 95% CI = 1.01–2.09] or North-Western province [aOR = 1.92, 95% CI = 1.31–2.82], and AGYW from communities with moderate wealth [aOR = 1.36, 95% CI = 1.01–1.85]. The intraclass correlation revealed that 8.9% of the overall variations remained unexplained after controlling for both individual and community-level influences. Conclusion The barriers to modern contraceptive use among adolescent girl and young women were younger age, not being married, no education or lower education, region, lower community wealth status, and high community employment status, contributing to lower uptake of modern contraceptives. Therefore, the prevalence of modern contraceptive use among adolescent girls and young women in Zambia remains low compared to the national target of 58%. This is despite many national and sub-regional family planning interventions aimed at accelerating uptake. The low prevalence of modern contraceptive use among adolescent girls and young women may imply an increased risk of unintended or mistimed pregnancies in this population group. This is because limited uptake of modern contraceptive use methods directly contributes to unmet need and reduce reproductive autonomy among young women. There is a need for tailored interventions addressing both individual and community-level barriers to enhance the utilization of modern contraceptive methods among adolescents and young women. Further research is required to identify effective strategies that can increase consistent and sustained use of modern contraceptives among this population.

Background Even though evidence shows that fertility transition has begun almost everywhere in sub–Saharan Africa (SSA), the decline has been slower than in other parts of the world. Research shows that there is a positive relationship between fertility levels and fertility preference. Therefore, many countries in the region are implementing family planning education campaigns targeting at influencing reproductive behavior of women. Thus, this study aimed to examine the extent to which exposure to family planning communication influences fertility preferences of adolescent girls in SSA. Methods This study used data extracted from the most recent Demographic and Health Survey datasets for 28 countries in SSA. Analyses were conducted on a pooled sample of 87,950 female adolescents’ aged 15–19 years who were captured in respective country’s survey. Multivariable binary logistic regression model was fitted in Stata version 17 software to examine the association between exposure to family planning communication and fertility preference among adolescent girls in SSA. Results The average fertility preference among adolescent girls in SSA was 4.6 children (95% CI: 4.5, 4.7). Findings show that regardless of the country, adolescents who had exposure to family planning messages [aOR = 0.76, 95% CI = 0.72–0.80] were less likely to prefer 4 or more children. On average, fertility preference among adolescents who had exposure to family planning communication was (3.8 children compared to 4.5 children; p < 0.001) among those with no exposure. Furthermore, results show that married adolescents in SSA who had exposure to family planning message had a higher average preferred family size compared to those who were not married (4.8 versus 3.8; p < 0.001). Conclusion Exposure to family planning communication has shown the potential to influence adolescents’ fertility preference in sub-Saharan Africa. Adolescents with exposure to family planning messages preferred a small family size. Therefore, there is a need to scale-up family planning education programmes in order to reduce fertility further in SSA.

Background Early childbearing remains a public health concern in sub-Saharan Africa (SSA) because it has substantial implications for women’s and children’s health and population control. However, little is known about recent changes in early childbearing in the region following the implementation of the Family Planning 2020 initiative (FP2020) national-level interventions. Thus, this study examined factors associated with early childbearing among women in SSA. Methods The study used data from the most recent Demographic and Health Surveys conducted in 31 countries in sub-Saharan Africa between 2010 and 2021. The analysis included a pooled sample of 54,671 parous young women aged 20–24 years. A multivariable binary logistic regression model was used to examine the association between early childbearing and individual and household-level factors. All analyses were weighted to account for complex survey design. Results The study shows that the mean prevalence of early childbearing was high in SSA at 39% (95% CI: 35, 43). Chad had the highest prevalence of early childbearing, 62% (95% CI: 60, 64) while Rwanda had the lowest prevalence of 13% (95% CI: 11, 15). Completing secondary school (aOR = 0.57; 95% CI: 0.52, 0.62) or attaining tertiary level education (aOR = 0.32; 95% CI: 0.22, 0.45), first sexual debut in the age range 15–24 years (aOR = 0.15; 95% CI: 0.14, 0.16) and desire for a small family size (aOR = 0.63; 95% CI: 0.58, 0.69) were associated with reduced odds of early childbearing among young women in SSA. Conclusion The study has established that the prevalence of early childbearing is high in SSA. Level of education, age at first sexual debut, household size, and desired family size are associated with early childbearing in SSA. Governments of SSA countries should enhance sexual and reproductive health interventions to change reproductive behaviour, particularly in adolescents and young women.

Background Several studies in sub-Saharan Africa and elsewhere have affirmed the importance of community-level factors in influencing maternal health seeking behaviour. However, literature shows no uniform pattern in terms of how contextual-level factors influence delay in seeking antenatal care service in different parts of the region. The association of contextual factors and timing of antenatal care is not well documented at regional level. Thus, this study was conducted to examine how community-level characteristics influence decision not to initiate antenatal care in the first trimester. Regional-level analyses of antenatal care utilisation in sub-Saharan Africa are important because they help identify geographic disparities in access and utilisation of the service. Thus, allowing for targeted interventions to improve maternal health outcomes. Methods Data from the most recent Demographic and Health Surveys conducted between January 2010 and December 2021 were used in this study. A sample of 222,436 women aged 15–49 who gave birth in the last five years preceding each of the 33 country surveys in the region was used in the analysis. The association between individual and contextual-level factors and timing of antenatal care was assessed using multilevel binary logistic regression models. Stata software version 17 was used to perform statistical analysis taking into account the complex survey design. Multivariable results were presented using adjusted odds ratios at 95% confidence interval. Results The prevalence of delay in utilisation of first antenatal care service in sub-Saharan Africa was 61.1% [95% CI, 60.6, 61.5]. Mozambique had the highest prevalence of 85.5% [95% CI, [84.2, 86.7] while Liberia had the lowest prevalence at 27.8% [95% CI, [25.6, 30.1]. Women in the age groups 25–34 [aOR = 0.79, 95%CI = 0.76–0.82] or 35–49 [aOR = 0.66, 95%CI = 0.63–0.69], those with secondary or tertiary education [aOR = 0.97, 95%CI = 0.93–1.01] and [aOR = 0.71, 95%CI = 0.66–0.77], belonging to rich households [aOR = 0.91, 95%CI = 0.88–0.95], and those who experienced a pregnancy loss [aOR = 0.84, 95%CI = 0.81–0.87] were less likely to delay first ANC utilisation. Conversely, women living in rural areas [aOR = 1.18, 95%CI = 1.13–1.23], communities with a high proportion of women who experienced unwanted births [aOR = 1.08, 95%CI = 1.02–1.14] were more likely to delay first antenatal care visit. Conclusion Both individual and community-level factors influenced women’s delay in seeking antenatal care service in sub-Saharan Africa. Integrating community level factors when designing maternal health promotion interventions would be key to improve early utilisation of antenatal care services. There is need to strengthen maternal health promotion initiatives such as Community Health Worker Outreach, Mobile Messaging Campaigns, Male Involvement Initiatives and, School and Youth Friendly Health Programmes targeting women in marginalised communities such as rural settings.

Sub-Saharan Africa (SSA), particularly Southern and East Africa, has the highest AIDS deaths and HIV-infected people in the world. Even though considerable effort has been made over the years to study HIV transmission risk behaviours of different population groups in SSA, there is little evidence of studies that have looked at pooled effects of associated HIV risk factors among men, particularly in Southern Africa. Thus, this study sought to fill this gap in knowledge by investigating the variations in HIV risk behaviours among men in the region. The study analysed cross-sectional data based on the most recent country Demographic and Health Survey (DHS) for six countries, namely Lesotho, Mozambique, Namibia, South Africa, Zambia and Zimbabwe. The study employed multivariate logistic regression models on a pooled dataset and individual country data to examine the relative risk of education and other factors on HIV risk behaviour indicators. It considered: (i) condom use during high risk-sex, (ii) multiple sexual partnerships, and (iii) HIV testing among men aged 15–59 years. Findings show that the proportion of men who engaged in HIV transmission risk behaviour was high in Southern Africa. Two-thirds of men reported non-use of a condom during last sex with most recent partners while 22% engaged in multiple sexual partnerships. The percentage of men who used condoms during sex with most recent partners ranged from 18% in Mozambique to 58% in Namibia. Age, residence, marital status and household wealth status were associated with HIV risk factors in the region. The study has established country variations in terms of how individual factors influence HIV transmission risk behaviour among men. Results show that the level of education was associated with increased use of condoms, only in Zambia and Mozambique. Delay in starting a sexual debut was associated with reduced odds of having multiple sexual partnerships in the region. Suggesting the need to strengthen comprehensive sexuality education among young men in school, to promote social behaviour change during adolescence age. The study presents important results to inform direct health policy, programme and government action to address HIV prevalence in the Southern region of Africa.

In many developing countries, population expansion and high fertility rates have been of concern to individuals, society, and governments. Zambia is one of the countries in sub-Saharan Africa, which has been experiencing high fertility for more than four decades since it attained independence. Understanding of factors associated with desired family size, especially amongst young women, is important because their future reproductive behaviour has the potential to influence the country’s course of fertility. Therefore, this study was conducted to examine the determinants of family size choice among young women in Zambia. The study analysed data extracted from repeated cross-sectional surveys conducted in 2007, 2013 and 2018. The analysis was done on a pooled weighted sample of 15,528 young women aged 15–24 years. Multivariate logistic regression was used to examine factors associated with the desired family size of young women. All analyses were conducted using Stata software version 17 and considered complex survey design. The prevalence of young women who had the desire of at least 4 children has been considerably high in Zambia, at 63.2%. Young women in the age group 20–24 were found to have higher odds (AOR = 1.31; 95% CI: 1.03, 1.66) of desiring at least 4 children compared to those aged 15–19. Women living in the rural areas were (AOR = 1.41; 95% CI: 1.10, 1.79) more likely to desire at least 4 children compared to their counterparts living in urban areas. Age of a young woman, place of residence, level of education, household wealth status, number of living children, and exposure to mass-media family planning messages were significantly associated with desire of at least 4 children. The desire for a large family size remains a social concern for reducing fertility in Zambia. This is because the proportion of young women who desire a large family size has been consistently high. Increasing access to education and sexual reproductive health information to young women especially to those in rural areas is key to changing their reproductive behaviour.

ObjectivesTo measure the sex-specific and community-specific mortality rates for adults in Lusaka, Zambia, and to identify potential individual-level, household-level and community-level correlates of premature mortality. We conducted 12 survey rounds of a population-based cross-sectional study between 2004 and 2011, and collected data via a structured interview with a household head.SettingHouseholds in Lusaka District, Zambia, 2004–2011.Participants43 064 household heads (88% female) who enumerated 123 807 adult household members aged between 15 and 60 years.Primary outcomePremature adult mortality.ResultsThe overall mortality rate was 16.2/1000 person-years for men and 12.3/1000 person-years for women. The conditional probability of dying between age 15 and 60 (45q15) was 0.626 for men and 0.537 for women. The top three causes of death for men and women were infectious in origin (ie, tuberculosis, HIV and malaria). We observed an over twofold variation of mortality rates between communities. The mortality rate was 1.98 times higher (95% CI 1.57 to 2.51) in households where a family member required nursing care, 1.44 times higher (95% CI 1.22 to 1.71) during the cool dry season, and 1.28 times higher (95% CI 1.06 to 1.54) in communities with low-cost housing.ConclusionsTo meet Zambia's development goals, further investigation is needed into the factors associated with adult mortality. Mortality can potentially be reduced through focus on high-need households and communities, and improved infectious disease prevention and treatment services.