Setting Regional Research Priorities for Sexual and Reproductive Health and Rights Services in Humanitarian Settings

Background: Despite increased recognition of the need for sexual and reproductive health and rights in humanitarian settings, evidence focusing on mainstreaming reproductive health services such as maternal, neonatal mortality, human immunodeficiency virus transmission and unsafe abortion still remains inadequate. The ability to understand the magnitude of the needs and highlight existing gaps is supported by improved data which is critical to informing effective policies, programming and funding decisions. The pur-pose of this report is to present the results of a research prioritization exercise on sexual and reproductive health and rights services in humanitarian settings for the WHO Africa region for the next three years. Methods: We adapted the Child Health and Nutrition Research Initiative method in three phases. Experts from the region participated in an online survey to identify key areas for research in sexual and reproductive health and rights. To identify potential areas for research, the experts ensured answerability, effectiveness, deliverability, equity and potential impact of the questions. The research areas tions to address sexual and reproductive health and rights services in humanitarian settings. Results: A list of 21 priority research questions on sexual and reproductive health and rights services in humanitarian settings were scored and ranked. Top ten priorities research questions were identified. Those that scored highly by scoring 30 points out of the possible maximum of 30 include: “determining the prevalence and associated factors of unwanted pregnancies and abortions performed in emergency and humanitarian set-tings”, “evidence on gender-based violence in humanitarian situations and its associated factors” and “defining an optimal model for coordinating sexual and reproductive health and rights interventions and responses in crisis situ-ations”. Conclusions: Top ten research priorities in sexual and reproductive health and rights services in humanitarian settings were identified. The priority research areas have the potential to identify the best areas for programming of services in humanitarian settings. It is our hope that the identified research areas will be prioritized to support programming of services in humanitarian settings based on scientific evidence.

Advances in Reproductive Sciences tions to address sexual and reproductive health and rights services in humanitarian settings. Results: A list of 21 priority research questions on sexual and reproductive health and rights services in humanitarian settings were scored and ranked. Top ten priorities research questions were identified. Those that scored highly by scoring 30 points out of the possible maximum of 30 include: "determining the prevalence and associated factors of unwanted pregnancies and abortions performed in emergency and humanitarian settings", "evidence on gender-based violence in humanitarian situations and its associated factors" and "defining an optimal model for coordinating sexual and reproductive health and rights interventions and responses in crisis situations". Conclusions: Top ten research priorities in sexual and reproductive health and rights services in humanitarian settings were identified. The priority research areas have the potential to identify the best areas for programming of services in humanitarian settings. It is our hope that the identified research areas will be prioritized to support programming of services in humanitarian settings based on scientific evidence.

Keywords
Humanitarian, Conflicts, Crisis, Sexual and Reproductive Health and Rights

Introduction
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 [1]. 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 [2].
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 [3]. 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 [4]. Globally, preventable deaths from diseases with risks factors point towards SRHR [5]. 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 [6].
According 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.

Methods
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. 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.

Results
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. 3) Effectiveness Based on the best existing evidence and knowledge, would intervention be efficacious in reducing disease burden? It is likely to be effective under programme conditions. 1-2-3-4-5

4) Feasibility
Taking into account a) the infrastructure and resources required to deliver effective interventions (e.g. human resources, health facilities, communication and transport infrastructure), and b) the need for change in demand, beliefs and attitudes of users, would you say that the endpoints of the research would be deliverable? Affordability and sustainability.

1-2-3-4-5 5) Burden
Diseases burden reduction; taking into account the best available information, would you say that reaching of research endpoints would eventually, have a "capacity" to impact directly and indirectly disease burden. E.g. up to 5% to 10% reduction in long run.  2) Evidence on gender-based violence in humanitarian situations and associated factors. 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.

Discussion
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 Advances in Reproductive Sciences and newborn care, and only three provided elements of clinical management of rape [14]. Safe abortion was unavailable across settings, despite unsafe abortion having been estimated to cause 25% -50% of maternal deaths in refugee settings [15]. 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 [16] [17].
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 [18]. 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 [19].
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 [20] 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.

Conclusion
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.

Authors Contribution
NT, OL, BF, MS, DK, DS, AC and EH conceptualized the exercise. KC, AM, TL