Recent systematic reviews have highlighted a scarcity of rigorous evidence to inform interventions in SRHR services in humanitarian settings despite the fact that global conflicts are widespread and they continue to affect many lives . For this reason, specific health problems in humanitarian settings whether caused by conflict, disease outbreak or disasters need relevant, require rigorous and up-to date evidence to guide appropriate responses. Often, multiple types of crises occur simultaneously such as armed conflict or natural disasters combined with famine and disease outbreaks. Although many researchers acknowledge that conducting research in humanitarian context response can be difficult and challenging, however, more research is still needed to provide evidence for improved solutions .
According to WHO, providing comprehensive SRHR services in humanitarian settings can yield important health and social benefits for vulnerable populations. The universal health coverage framework focuses attention primarily on comprehensive sexual and reproductive health and rights services for the most vulnerable communities including those in humanitarian settings . It is estimated that about 135.7 million people around the world have been affected with women and girls of reproductive age bearing the heaviest burden . Globally, preventable deaths from diseases with risks factors point towards SRHR . These crises have long-term health eventualities on many people affected by such crises especially in low and middle-income countries (LMIC), yet the evidence base that informs THE response in humanitarian settings is weak .
According to WHO, humanitarian emergencies often have a disproportionate effect on the poorest and most vulnerable, particularly women, adolescents and children. There is often lack of SRHR services including family planning, saving lives in obstetric complications and even preventing diseases  . Maternal and neonatal mortality is high in the areas affected by emergencies. Universal access to health that integrates comprehensive SRHR services is critical to reduce related morbidity and mortality.
Due to the varied nature of conflicts and other related crises that cause human suffering, deficiency of evidence is common. It is therefore imperative that evidence based research priorities are identified to ensure appropriate interventions are provided  . Additionally, humanitarian responses cannot be expected to achieve optimal health outcomes without a rigorous and scientific evidence base  . Prioritizing health research in these settings is often very difficult and currently there is a limited amount of scientific evidence that can inform effective humanitarian responses to guide governments, development agencies and humanitarian organizations.
There is a justification to conduct priority research that can inform relevant responses to policies, programs and interventions amongst other health challenges and their outcomes. Research prioritization is a prime mechanism for evidence-based policies and interventions towards better global health. It is against this background that the WHO African Region undertook an exercise to identify research priorities in SRHR services in humanitarian settings to guide the research agenda for the next three years and also to guide countries to improve their ability to respond to the circumstances. Such priorities would serve to elucidate key areas of research focus.
This paper reports part of a larger research prioritization exercise conducted by the WHO African region. The paper focuses on sexual and reproductive health and rights services in humanitarian settings. The research prioritization exercise adopted the Child Health and Nutrition Research Initiative (CHNRI). A consultative and consensus based approach with experts in SRHR taking into consideration their voices produced the first potential areas for debate. In considering the questions for discussion, the experts were guided by the following qualities; answerability, effectiveness, deliverability, equity and potential impact of the areas. The implementation was process took three phases. 1) Generation and collection of researchable questions online using experts 2) review, consolidation and thematic analysis of the potential research by WHO HQ experts and 3) scoring and ranking of the questions to identify priority questions using pre-defined scoring criteria.
In the first phase, an online questionnaire was administered in August 2019 to SRHR experts in various countries across the region to collect potential areas of research in sexual and reproductive health and rights. The countries included Benin, Burkina Faso, Chad, DRC Congo, Ethiopia, Rwanda, South Africa, Ghana, Kenya, Nigeria, Mali, Guinea and Central Africa Republic. The online suggestions were received by a technical team of WHO HQs in September 2019 for review and consolidation. The online survey built on the results from a prior research prioritization exercise conducted by EMRO and AFRO in 2016 .
Both the second and third phases of the research prioritization process were conducted in a meeting held in Cape Town, South Africa from 29th October to 1st November, 2019. A total of 67 participants from the 80 who were invited attended. The experts worked in 12 groups to work on the questions that were organized into 12 thematic areas. The group work entailed reviewing the questions to remove the questions that were out of scope and those that appeared to have duplications were merged. A total of 21 research priority questions on sexual and reproductive health and rights services in humanitarian settings were proposed for level three.
During the third phase of the research prioritization process, four experts analyzed the 21 questions from phase 2. Using the scoring criteria in Table 1, the questions were scored and ranked. The scoring criteria had 1 as the lowest score and 5 as the highest score. Each question could therefore attain a lowest score of 6 or highest score of 30.
The aim of the exercise was to identify priority research questions on SRHR services in humanitarian settings. In this paper, we report a part of the results of a research prioritization exercise focusing on sexual and reproductive health and rights services in humanitarian settings. 67 experts participated in the meeting thereby eliciting a response rate of 83.7 percent.
The scores ranged from 30 to 25 points for the top ten priority questions. Table 2
Table 1. Scoring criteria.
1 is the lowest score and 5 the highest score. Each question could therefore attain a lowest score of 6 or highest score of 30.
Table 2. Top ten research priority questions on SRHR services in humanitarian settings.
presents the distribution of the results as ranked. The top three questions include; “determine the prevalence and associated factors of unwanted pregnancies and abortions performed under conditions of humanitarian emergency”; “evidence on gender-based violence in humanitarian situations and associated factors”; and “defining an optimal model for coordinating SRHR interventions and responders in crisis situations”. The other research question that was ranked high at 28 was “assessment of the scope and operational capacities of psychosocial services in humanitarian situations”. The question that received the lowest score of 25 points out of the ten was on “the extent, types and complications of non-communicable diseases in pregnant women in humanitarian situations”. The priorities identified should support decisions as humanitarian action relies on a broad range of evidence ranging from quantitative data from surveys, from experts inputs as well as from routine programme monitoring.
A 2015 study from three crisis-affected settings in sub-Saharan Africa found that only five of 63 assessed health facilities provided adequate emergency obstetric and newborn care, and only three provided elements of clinical management of rape . Safe abortion was unavailable across settings, despite unsafe abortion having been estimated to cause 25% - 50% of maternal deaths in refugee settings . Certain groups, such as adolescents and older women, male survivors of sexual violence, sex workers, people living with disabilities or those of diverse sexual orientations and gender identity and/or expression continue to face significant obstacles in accessing information and services in humanitarian settings  .
Major challenges in conducting rigorous research in SRHR services in humanitarian settings is because most of the research is done by persons involved in delivering aid thus research takes the second place after providing lifesaving. Deficient health systems, shortages of skilled health providers, supply stock-outs, and restrictive policy environments hinder effective SRHR service provision in crisis situations. Humanitarian crises expose weaknesses in health systems, with particularly serious consequences for women, young people and marginalized groups. Often, these challenges were present before the crisis and are further exacerbated by the humanitarian situation. Socio-economic and cultural barriers, gender inequality and a lack of information about the availability and benefits of care also impede service uptake . Addressing these challenges requires harmonization of efforts and improved organizational policies, but most importantly sufficient funding and adequate capacity.
Integration of sexual and reproductive health and rights into humanitarian and fragile settings responses has grown globally. The awareness of the consequences of neglecting reproductive health services, such as maternal and neonatal mortality, HIV transmission, and unsafe abortion, has expanded . Since the 1990’s recognition of SRHR needs for crisis affected persons has grown slowly in the international community starting with the development of the UNHCR guidelines on protection of refugee women  and to date a global action declaring access to comprehensive SRHR is a basic human right. Our research prioritization exercise recommends that research for SRHR services in humanitarians settings respond to these recognized priorities. This is because humanitarian needs are varied and the only way to take action on the people affected differently by the crises requires relevant knowledge that is contextualized to respond appropriately.
Priority research areas in sexual and reproductive health and rights services in humanitarian settings were identified. Rigorous, scientific research that assesses the scope of SRHR services in humanitarian settings, examines cost effectiveness, beneficial public health interventions and translates evidence to practice is critical to the WHO Africa region.
NT, OL, BF, MS, DK, DS, AC and EH conceptualized the exercise. KC, AM, TL provided technical support. All authors read and approved the final manuscript.
We thank all the experts who were involved in the research prioritization exercise for WHO Africa Region. They include: Zan Souleymane, Moufalilou Aboubakar, Bokossa Alexis Richard, Gaston D. Ahounou, Dina Gbenou, Hien Clotaire, Kiemtoré Sibraogo, Traoré Isidore Tiandiogo, Bassounda, Poïdigem, Dadjoari Moussa, Nguetabe Odile, Awad Adam Awad, Foumsou, Kini Brigitte Nsiku, Haimanot Ambelu Workineh, Tenaye Kebede, Girma Gemechu, Mekdes Daba, Deo Roseline, Samuel Oppong, Ivy Osei, Patrick K. Aboagye, Sy Telly, Férida Mara, Alpha Ahmadou Diallo, Tessougue Fatoumata, Idrissa Cissé, Sidy Diallo, Ben Moulaye Haidara, Moussa Kamissoko, Ojo Olumuyiwa, Ufere Joy, Ikpeze Okechukwu Christian, Chris Ega, Kabuteni Theopista John, Utumatwishima Jean Nepo, Ndaruhutse Victor, Ruzindana Kenneth, Mihretu Belete, Sithembile Dlamini-Nqeketo, K.S. Dithole, Rapinyana O., Ntombi Mtshali, Mercy Pindani, Azwihangwisi Helen Mavhandu-Mudzusi, Uta Lehmann, Boniface Ushie, David Norris, Blami Dao, Issiaka Sombie, Seni Kouanda, Richard Adanu, Goma Mboungou Mierette, Mavounia Ndoko Genil, Ngwenya, Mmamoitlamo and Mncwabe Pearl.
The WHO Regional office for Africa.
CHNRI: Child health and nutrition research initiatives; WHO: World Health Organization; UHC: Universal health coverage; SRHR: sexual and reproductive health and rights.
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