Technical Workshop on Setting Research Priorities for Reproductive Health in Crisis Settings: Summary of Proceedings

Transcription

1 Technical Workshop on Setting Research Priorities for Reproductive Health in Crisis Settings: Summary of Proceedings Center for Global Health Division of Global Disease Detection and Emergency Response CS A

2 Background By the end of 2010, more than 40 million people were displaced due to conflict in 22 countries and a majority are in the developing world. 1 In addition another 40 million people were displaced due to natural disasters. 2 Women and children make up a majority of the affected population. 3 Because of their gender and age, women and children face unique challenges including health issues related to pregnancy, delivery and postnatal care, sexual violence, and transmission of sexually transmitted infections including HIV/AIDS. Although the humanitarian community is keenly aware of the impact of crises on the health status of women and children there is still an ongoing need to provide high quality services in emergencies to decrease the burden of poor reproductive health (RH) outcomes. The Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis was formed in 1995 to exchange information, identify challenges, gain from the experience of others, build partnerships, and collectively work toward the institutionalization of reproductive health care for populations affected by crises. In the past two decades there has been increased research activities targeted to describe the scope and magnitude of the burden of RH outcomes, improve program interventions and inform policy and advocacy. Various conferences and meetings have been held to review and exchange research findings, identify crucial needs (e.g. the importance of RH preparedness efforts) and to develop appropriate tools such as the Minimum Initial Service Package (MISP) on RH. Assessments and studies undertaken in documented the gaps in resources and guidelines for providing RH for refugees and internally displaced persons (IDPs). These findings led to the development of the first version of the Inter-Agency Field Manual on RH in Refugee Settings in and published in In 1998, the Population Council and the Center for Population and Health at Columbia University s Mailman School of Public Health hosted a meeting to discuss research needs and develop a plan of action focusing on RH in refugee settings. Research gaps identified fell into three main categories: i) Basic epidemiology of RH problems in refugee settings ii) Program operations iii) Policy issues In 2000, the Reproductive Health for Refugees Consortium Research Conference was held at which priority needs for the field were identified as a: i) Focus on the RH needs of adolescents ii) Means to stop HIV transmission iii) Multi-sectoral response to sexual and gender-based violence (SGBV) The 2003 Reproductive Health From Disaster to Development conference promoted the exchange of applied research and sharing of evidence-based models of service delivery, which contributed to improving servicedelivery to conflict-affected populations. While it was noted that data collection had improved substantially, gaps remained in applied research on safe motherhood, family, HIV, SGBV, adolescent and youth services, and involvement of men and boys. In 2004, the IAWG completed a global evaluation documenting the overall progress of RH from 1995 to 2004; findings showed that services, manuals and strategies were better implemented in refugee and stable settings compared to IDP and emergency settings. The Reproductive Health in Emergencies (RAISE) conference in 2008, provided an additional opportunity to share research, programs, innovative strategies and programs, and practical tools and guidelines. In 2009, representatives from UN agencies and other humanitarian partners agreed on the Granada Consensus on Sexual and Reproductive Health in Protracted Crises and Recovery to advocate for mainstreaming sexual and RH throughout the emergency management cycle and in protracted crises and recovery, to secure the commitment of humanitarian and development actors, and to bridge current service delivery and funding gaps. 2

3 With this foundation, the IAWG sub working group on Reproductive Health Data, Health Information Systems (HIS) and Research (IAWG RHR SubWG) organized the Technical Workshop on Reproductive Health in Crises: Setting Research Priorities to provide a forum to further discuss the current research gaps and to develop a collaborative plan of action to address them in the near future. This two-day workshop was hosted by U.S. Centers for Disease Control and Prevention (CDC) and Columbia University, Mailman School of Public Health on June 28 29, 2011, at the CDC Headquarters in Atlanta, Georgia. The workshop gathered 25 experts on RH in crisis settings from UN organizations, International Non-Governmental Organizations, academic experts and donors. Workshop Objectives The purpose of the technical workshop was to set a research agenda for the field of reproductive health in crises for IAWG partners to jointly work on over the next calendar year. The objectives were to: Present a short list of existing research questions and select priorities Identify research questions and methods Create a collaborative plan of action to implement the research Research Question Selection Process The IAWG RHR SubWG developed a primary list of 28 research questions/gaps, collected from prior meetings, working groups and evaluations. This list was sent to 36 individuals who were asked to review and submit any additional questions pertinent to their organizations. Sixteen individuals responded. The expanded list included 94 research questions, divided into eight categories (Adolescent RH, comprehensive abortion care, family, MISP, maternal & newborn health, SGBV, HIV/STI and cross-cutting). In order to identify the most salient research questions/gaps, the IAWG RHR subwg developed five inclusion criteria: need, feasibility, operationalizability, usefulness and relevance (Table 1). An online survey was sent to the same initial list of individuals and they were asked to triage the list of questions according to the selected criteria by answering: Yes, No or Don t know. An overall (unweighted) research priority score (RPS) was calculated for each question. To identify the top questions, a cutoff of 0.65 was used, which produced a shortlist of 28 questions; the diverse questions/topics represented the interests of virtually every agency and individual participating in the process. The respondents weighted the importance of each criterion in order to calculate a weighted RPS. After weighting, the same questions emerged as the top 28. In addition, to assess the level of consensus with respect to the short-listed items, an average expert agreement (AEA) score was generated for each question based on the average most frequent response for all the criteria. In keeping with other such exercises, 4, 5 the AEA overall showed a direct positive association with RPS, indicating that agreement among experts was greater for the top-ranking questions than for the lower ranking questions. The list of the 28 top research questions/topics is provided in Table 2. 3

4 Table 1. Inclusion Criteria for the Selection of Proposed Research Questions Criterion Need Feasibility Operationalizability Usefulness Relevance Definition Does this question have the ability to provide fresh insight or enhance prior research? Does the question address a critical research gap? Can data on the question be collected given human resources, funding and other logistical constraints? Can it be collected in a complete, reliable, and valid manner that ensures good data quality? Is the question measureable? Can research findings be applied to improve service delivery? Do partners have the ability to use the information for multiple purposes (e.g., for ongoing program, routine monitoring, quality improvement, accountability to donors)? Does the research question directly address the identified RH gap or issue? Table 2. Top Ranked Research Questions/Topics (RPS> 0.65) Rank Research Question Topic Category RPS* AEA* 1 Does training and supporting community-based organizations on the MISP and MISP contingency for emergency preparedness and disaster risk reduction lead to improvements in implementation of the MISP? * RPS: Research priority score; AEA: Average expert agreement; MISP: Minimal Initial Service Package; MNH: Maternal & newborn health; Note 1: cross-cutting includes methods, surveillance anything that did not fit in a category of MNH, SGBV, HIV/STI or Planning. Note 2: questions were kept in their original wording 4 MISP* How can Basic EMOC care be integrated to health centers and primary level health facilities in emergency settings? MNH* What are structural and implementation bottlenecks to implementing the MISP and comprehensive RH including GBV in emergencies and what are promising interventions to overcoming these? In what ways do conflict and/or humanitarian emergency situations impact individuals childbearing intentions and fertility-related decision making, as well as fertility-related attitudes more broadly at the societal level? Is the integration of new technologies for post-partum hemorrhage such as misoprostol and the non-pneumatic antishock (NASG) garment safe, feasible and effective in stable crisis-affected settings? MISP* Planning MNH* What are the best ways to deliver and strengthen comprehensive GBV and STI/HIV/AIDS services in refugee settings and IDPs? Cross-cutting What is the need for services to address and prevent unintended pregnancies and their sequelae in emergency situations? Is community-based distribution of family services, including injectables, applicable and feasible in humanitarian settings and does it enhance people s access to and use of contraceptives? What is the role of misoprostol for PPH in the emergency context particularly at the community level (in line with WHO recommendation on its use)? What is, or could be, the role of new (media) technologies for improving access to RH services in crises such as arcmap/ GIS, Cell phone technologies, Social media? What is the availability of family methods and the skills and abilities of service providers? Study acceptance of IUDs in crises settings. circumstances? By whom? Is safe abortion available to all women in crisis in accordance with country law - e.g., to save the life of the woman, on grounds of health, on grounds of mental health? Under what circumstances? By whom? The magnitude of unsafe abortion and its actual contribution to maternal mortality in the refugee/idp context MNH* Cross-cutting Comprehensive abortion care Comprehensive abortion care Study approaches for reaching adolescents in humanitarian settings. Adolescent RH* Harmonize existing MISP-related assessment, monitoring and evaluation tools MISP* What are the main RH indicators to include when you set up a surveillance system in humanitarian emergency? In other words, if you had to chose 1-2 indicators as a must have, what is/are the most critical indicator/s to include? Cross cutting Does the risk of adverse obstetric outcome change in an emergency? If a higher risk exists, what are the possible causes? MNH* To what extent, if at all, has the humanitarian community made progress with regard to meeting the family needs of crisis-affected adolescents and young adults? What are the effects of births kits on clean birth practices and on newborn and maternal outcomes? MNH* Is community-based care for survivors of sexual violence safe and feasible in humanitarian settings? SGBV Design and conduct a larger trial of a pilot study that used a community-based support and follow-up system activated when a woman going into labour needs, for example, emergency transport or someone to look after her children. A recent systematic review (Lee et al., 2009) concluded that evidence is promising, albeit limited, that community referral and transport schemes may increase uptake of SBA and EmOC, however a larger trial is needed. What are the strengths and limitations of family services in conflict-affected countries (government, private) with regard to budgets, logistics, training personnel, and innovative approaches for reaching populations in crisis? Abortion technologies What is available/being used? (MVA, sharp curettage, miso-only, mife+miso, etc)supply issues? What are the training needs? MNH* Comprehensive abortion care How accessible are services for adolescents? Adolescent RH How can services for the prevention and response to GBV and HIV/AIDS prevention and obstetric emergencies be improved especially for IDPs? Cross-cutting What strategies exist to fill in health workforce gaps in emergencies? For example, task shifting as a mechanism to fill in the gaps. Cross-cutting What is the effectiveness and feasibility of basic EMOC on saving maternal and newborn lives in emergencies, and how do we measure it to demonstrate impact? MNH*

5 Group Roles Researchers, implementers and funders were divided amongst the four working groups to ensure that there would be balanced representation of participants in each group. Each group had three main tasks: 1) To select and clearly define one or two research questions from the list 2) To design a study appropriate to address the selected research questions 3) To create a collaborative plan of action to implement the proposed studies Small Group Working Process: Selecting the Priority Questions Each group received a shortlist with seven randomly assigned research questions drawn from the 28 top questions. Members then discussed and prioritized these questions, eventually choosing one main and one alternative research question. All groups discussed the pros and cons of each question in their respective lists; however, each group took a different approach in prioritizing them. These approaches included: i) Grading questions based on four criteria (feasibility, operationalizability, usefulness and relevance) ii) Examining the importance of the topic/s that were associated with each question iii) Reviewing all similar questions on the category-specific list provided by organizers This last approach helped in rephrasing the overall question as needed. One group identified the need for another global evaluation to identify RH gaps and strengths in services for all emergency-affected populations and to provide a picture of the current state of RH in crisis in lieu of questions from the short list provided. In the decision process, one highly important criterion was originality of the question intended to prevent duplication of effort (e.g. where any agency is currently working or has worked on the same or similar topic). This point also highlighted the fact that systematic literature reviews would be helpful in answering and refining the questions. Group discussions and presentations on selected questions offered a chance for all participants to share information about their respective agencies research efforts and about ongoing or previously conducted studies that addressed a similar problem. After presenting the selected question/s to the plenary, small group participants designed a research proposal which included refining the research question, identifying study methods, selecting potential sites, identifying necessary and/or available resources, limitations, and funding opportunities. Lastly, groups drafted a plan of action to preserve and guide the implementation of the research projects by dividing tasks and selecting a focal point. During group meetings, participants had the flexibility and choice to join any group based on specific questions, interest and expertise. To assist the participants, six standardized worksheets (proposal abstract, concept paper, group work plan, project timeline, project budget and project debrief presentation) were provided. Note takers assisted in populating these worksheets as appropriate. Two statisticians joined the workshop to answer technical methodological issues. Limitations The Research Question Selection Process limitations included time, low response rate, and variety of question types (e.g. qualitative vs. quantitative). In addition, other important criteria could be included in the selection process such as: ethics, equity and donor perspectives. Due to time constraints during the workshop, it was not possible for groups to finish working through all worksheets and to agree on a robust work plan. However, all groups finalized their abstracts provided in this document and prepared presentations for a debrief with open discussion and feedback. 5

6 Summary of the Research Question Selection Process 94 Research Questions/Topics - Collected from meetings, working groups & evaluations - Proposed by agencies and researchers - Applied the inclusion criteria Then - Calculated the RPA & AEA 28 Research Questions/Topics Each group was given a randomly assigned shortlist of 7 Reasearch Questions/Topics Group A Selected Global Evaluation Group B Selected as a 1st Choice: Rank #9 2nd Choice: Rank #1 Group C Selected as a 1st Choice: Rank #19 2nd Choice: Rank #5 Group D Selected as a 1st Choice: Rank #3 2nd Choice: Rank #11 Agencies that Participated in the Research Question Selection Process and/or the Technical Workshop. CARE * Centers for Disease Control and Prevention * Columbia University, Mailman School of Public Health * Emory University * Independent consultant * International Rescue Committee * International Planned Parenthood Federation IPAS John Snow, Inc Medecins Sans Frontieres, Spain and Switzerland * Save the Children * UN Children s Fund * UN High Commissioner for Refugees * UN Population Fund * USAID Office of Foreign Disaster Assistance * US Department of State Bureau of Population, Refugees, and Migration * Women s Refugee Commission * World Health Organization * Provided questions or input into Research Topics. * Attended the technical workshop. 6

7 Group A: Global Review of Reproductive Health Services in Crises The last comprehensive review of reproductive health in crisis was finalized in Agencies utilized the review to expand programs and advocacy on reproductive health for crises-affected populations. The current scope, coverage, quality, and impact of reproductive health services on the population of refugees and IDPs (people affected by humanitarian crisis) are unknown. In order to better guide field programs and agency activities, an updated field review is needed to identify services, quantify progress, document gaps, and determine future directions for programs, advocacy and funding priorities. This process is also essential to prepare for ICPD 2014 and ensure that the current state of the field of reproductive health in crises is represented. To accomplish these goals, a multipronged approach is proposed under the spearhead of a diverse steering committee as yet to be assembled. Potential activities to be completed by 2013 include a comprehensive updated literature review, global mapping of the reproductive health services provided by agencies in refugee and IDP settings, an in-depth analysis of service provision, quality and utilization in 6 10 selected sites, an investigation of funding trends, and a review of UNHCR surveillance system findings. These components may be conducted by a variety of agencies or research groups with the intention of disseminating findings through publication series and international conferences by Focal Point: Nadine Cornier UNHCR CORNIER@unhcr.org Group B: Assessing the feasibility, acceptability, safety, and adherence to self-administered Misoprostol for the prevention of post partum hemorrhage through community-based distribution in conflict-affected settings Women in conflict settings have high risk of delivery without skilled birth attendants. Misoprostol, an inexpensive heat-stable synthetic prostaglandin E1 (PGE1) analogue, can be used to prevent post partum hemorrhage (PPH). Unattended deliveries, with no access to active management of 3rd stage or oxytocin may benefit from misoprostol administration for PPH prevention. Misoprostol has been used in healthcare settings with success, however there is limited knowledge on whether community based distribution of Misoprostol is feasible, acceptable, safe, and has adequate adherence for self-administration in conflict settings. Quantitative and qualitative methods will be used to tracking adherence through a HIS and community health workers feedback will be used to assess acceptability and distribution. The study may also include comparison groups for women who refused the medication or did not use it. The sample size for the quantitative study will be calculated once the number of pregnant women during the enrollment period (fertility rate) is known. Criteria for site selection include: 1. Functioning health services, with strong tracking system (ex: HIS), 2. Strong community health workers networks and home visits programs, 3. Low facility based deliveries, 4. High maternal mortality (greater then 400 / 100,000 live birth), 5. Access to referral hospital. Suggested areas include Chad, Yemen, Kenya, and the DRC. The study is considering comparing two different sites/populations such as camp refugees and IDP situation. Anticipated partners include IAWG partners working on selected sites and local partners. Focal Point: Eva Lathrop Moore, Emory evalathrop@hotmail.com Group C: Assessing Contraceptive Services- Obstacles and Use Among Youth (Ages 10 18) in a Protracted Emergency. The Democratic Republic of Congo, a country experiencing a protracted humanitarian crisis, has a contraceptive prevalence rate of 20.6%, and an annual adolescent birth rate (15 19) of 198 per Adolescents are a vulnerable underserved group, with high rates of sexual abuse predisposing them to HIV/AIDS, unwanted pregnancies and STIs. While several NGOs provide reproductive health services in DRC, no evaluation has been conducted to assess the extent to which these services are accessed and utilized by adolescents. The study goals are to assess the availability of family services, determine contraceptive knowledge, attitudes and practices (KAP) and identify barriers and determinants for contraceptive access and use among youth in the DRC. Mixed methods, qualitative (focus group discussions of key informants) and quantitative (KAP) survey will be conducted in a collaborative study with UNICEF, UNFPA, CARE, IRC, and CDC. The study will take place in Rural: North Kivu, Maniema and Kinshasa. Study findings will be used to increase the availability, access, acceptability and use of contraceptives among adolescents and youth, by influencing programs and donors. Focal Point: Mary Yetter CARE myetter@care.org Group D: Identify Barriers and Facilitators of EmOC Implementation in an Acute Emergency Setting as Part of Minimal Initial Service Package (MISP) MISP, introduced in 1996, is the foundation for addressing reproductive health in emergencies. Since its implementation, evaluations of the implementation have used only formative assessment tools with limited rigorous comprehensive methodology. There is a need to more rigorously evaluate MISP implementation. The implementation of emergency obstetric care (EmOC), one component of MISP, in an acute emergency setting will be evaluated in order to identify barriers and facilitators of implementation and better understand how to improve EmOC implementation in acute phase of an emergency. Prior to conducting the evaluation a complete literature review will be completed to determine the evidence for past successful complete implementation of MISP in humanitarian settings. After the literature review, a prospective assessment of EmOC implementation in an acute emergency setting will be conducted to identify and categorize bottlenecks to implementation of EmOC. The evaluation will be used to determine what components of MISP are challenging and why. Advance preparation for the evaluation will include methods and tool development, prior IRB approval, and collaboration with organizations with broad multi-national infrastructure in order to pre-train personnel for quick mobilization of national support (eg FIGO, ICM, IRC). Findings on potential barriers from the literature review, which may include human resources, security, supply chain, funding, technology, community acceptance, will be incorporated in the evaluation. Focal Point: Lisa Thomas WHO thomasl@who.int 7

8 Next Steps Participants indentified and divided tasks for the implementation of their research projects. The first task was to perform a literature review for each research question. Other tasks included advocating and networking with other possible field partners and donors who might be interested in the research project. They also drafted workplans and timelines for their next activities, tailored to each project. Getting Involved If you are interested in any of the four research questions and would like to get involved in the research projects, kindly contact the focal point listed below the abstract. For any additional questions or workshop materials such as the full list of questions and the groups worksheets, please contact IERHB@cdc.gov. References 1. UNHCR Global Trends Internal Displacement Monitoring Center. Displacement due to natural hazard-induced disasters, Global estimates for 2009 and UNFPA. State of the World Population Lawn J E, et al. Setting Research Priorities to Reduce Almost One Million Deaths from Birth Asphyxia by PLoS Medicine (2011). Volume 8, Issue 2: e George A, et at. Setting Implementation Research Priorities to Reduce Preterm Births and Stillbirths at the Community Level. PLoS Medicine (2011). Volume 8, Issue 1: e This report was produced on behalf of the IAWG sub working group on Reproductive Health Data, Health Information Systems (HIS) and Research by: Centers for Disease Control and Prevention International Emergency & Refugee Health Branch 4770 Buford Highway, NE Atlanta, GA USA Phone: Fax: Columbia University Mailman School of Public Health 60 Haven Avenue New York, NY Phone: Fax: