most at risk adolescents in eastern europe building the evidence base joanna busza & megan...
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Most at Risk Adolescents in Eastern Europe
Building the Evidence Base
Joanna Busza & Megan DouthwaiteLondon School of Hygiene & Tropical Medicine
September 2, 2009
Research as process … study design, data collection, and analysis remain flexible and adapt as new questions or findings emerge.
Research into action … more important to produce useful information with practical implications than to create a lot of data.
Research for skills building …systematically working through each step strengthens collaboration within country teams and the region.
LSHTM approach to technical assistance
Technical Assistance Proposed Structure
1) Regional training & study design workshops
2) Development of standardised tools3) Guidance on country-specific issues4) Data analysis workshops 5) Country visits for specified activities6) Distance based backstopping &
advice
Select local sample populations & recruitment strategies
Synthesise available data
Collect data on risk & protective behaviours(7 countries)
Explore context & dynamics(4 countries)
Identify knowledge gaps on MARA
Develop interventions
Analyse costs and effects; Follow-up survey (?)
Process evaluations(3 countries)
Research Cycle
Choosing the right methodology is a logical
process, with several decision-making steps
… Exploring an unknown subject …… Gathering population-based data...… Comparing across the region ….… Planning interventions …… Evaluating services …
Designing Baseline Studies
1) What data on MARA already exists?2) Who has contact with target
groups?3) What are the advocacy objectives? 4) What are plans/ goals for
interventions?5) What is the main purpose for the
evidence produced?
Risk vs. Vulnerability
Assess & profile % of most-at-risk populations who are
adolescents?
OR
Determine & characterise % of specific adolescent groups who are involved in risk behaviours?
Eco-social framework for Risk
Individual
Communitycontext
Structuralshapers
Peer norms &Networks
Available services
Local Environment
SkillsKnowledge
Risk perception
LawsPolicies
Cultural attitudes & expectations
Politicaleconomy
Biological
Susceptibility
Research Components1) Sample selection2) Development of instruments3) Adaptation to country-specific contexts4) Addressing ethical issues5) Data analysis and interpretation 6) Qualitative studies in select countries to
explore specific dimensions of MARA experience
7) Intervention research in 3 countries to evaluate & cost MARA-targeted services
Identify 2nddarysources of data
Distill mostimportantfindings
Present resultsin clear format
Combine qualitative andquantitativedata
Offer rigorousinterpretation
Data adequate foraction
Results widelydisseminated
Findings in formcompatible withother data
Contributes towider evidence base
Interventions canbe planned ormonitored
Compile & interpret
existing data
Identify information
gaps
Design study
Select sampleand tools
Train team
Use appropriatefieldworkers
Monitor qualityduring research
Collect informationfrom multiple
sources
Manage ethical &logistic issues
Planning Data Collection Analysis Results/Use
Research Trajectory
Sampling MARA
1) Venue based2) Institution based3) Chain Referral
Respondent Driven SamplingNetwork recruitmentSnowball sampling
4) Convenience5) Combined sampling
approaches
Developing Indicators
Research design workshop, Belgrade
Integrating risk and vulnerability measures
Ensuring ability to compile UNGASS indicators
All MARA behaviours included
≈40 standardised core indicators + flexibility for country-specific topics
Data Collection Tools
LSHTM drafted male & female core questionnaires
Colour-coded core and recommended questions
Feedback incorporated from country teams
Each country adapted, translated and pilot tested
Guidelines distributed for compiling indicators
Core Questionnaires
Eligibility criteria Demographic profile Injecting drug use (frequency, drug
choice, and sharing practices) HIV knowledge Sexual behaviour (including
commercial & casual partnerships) MSM behaviour Access and use of services
(including condoms & HIV testing) Experience of detention
Diversity of Study Populations & Methods
Focus on Risk
Young IDU in Serbia, Romania, Moldova, Albania
Young sex workers in Romania & Albania
Young MSM in Albania & Moldova
Focus on Vulnerability
Young people in Roma settlements in Montenegro
Institutionalised settings in BiH & Moldova
Street children in Ukraine
Sample Populations: IDU
Recruitment Reached
Albania RDS 124
Moldova RDS 369
Serbia RDS 320
Romania RDS 300
Recruitment Reached
Albania - MSM
RDS 50
BiH- institutions
ALL 392
Moldova – institutions
ALL 81
Montenegro –Displaced
Roma
Venue-based/Snowball
290
Ukraine – Street
children
Network/ Snowball
805
Sample Populations: Other
LSHTM Analysis
Analysis conducted for 6 data sets
Romania FSW Romania IDU Serbia IDU Moldova IDU Montenegro Roma Ukrainian street children
LSHTM Analysis
Standardisation across data sets Age range limited to 15-24 EXCEPT
for Ukraine (10-19 yrs) Selection of indicators that maximise
comparability across the region Disaggregation by country, age and
sex Chi-square test for statistical
significance (& Fischers exact test where numbers <5 per cell)
Data QualityStrengths - Relatively good quality re:
internal consistency within data setsWeaknesses - Caution required in
interpretation of some variables due to small numbers
Some variation in way questions were asked
Cleaning issues – Skip patterns not all followed correctly, making it difficult to choose questions for compiling indicators
IDU Risk Profiles% Injecting Daily
Moldova 2.6
RomaniaIDU
76.2
RomaniaSW
88.3
Serbia 46.3
Ukraine 5.3
% Sharing injecting equipment past
monthMoldova 88.1Romania
IDU19.0
RomaniaSW
71.0
Serbia 35.1Ukraine 34.8
IDU Diversity of injecting drug use patterns
among the study samples
Moldova has a greater % of young IDU, but injecting behaviour is sporadic
In Montenegro, no IDU behaviours reported among IDP Roma
Sex workers who inject drugs may have riskier behaviour and poorer service use
Sexual Behaviour
All studies found high rates of sexual experience, including among adolescents.
Sexual experience increases with age
Condom use follows familiar pattern, with decreasing consistency for longer term partners
MSM behaviours rare, with exception of Montenegro and Ukraine sites.
Service Use Pharmacies appear acceptable source
of both injecting equipment and condoms
Knowledge of services higher than use
Surprising number of respondents ever tested for HIV, and this increases with age
Low use of rehabilitation services, especially among adolescents.
Knowledge by Age
0
10
20
30
40
50
60
70
80
90
100
15-17 Knowledge of HIV sexual transmission (G01&G02)
18-24 Knowledge of HIVsexual transmission
15-17 Knowledge of HIV transmission through IDU (G06)
18-24 Knowledge of HIV transmission through IDU
Moldova (IDU) Serbia (IDU) Romania (IDU) Romania (FSW) Ukraine Montenegro
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Service use by Age
0
10
20
30
40
50
60
70
80
90
100
15-17 Ever had HIV test 18-24 Ever had HIV test 15-17 Obtainedneedles/syringes fromexchange/dropin &/or
outreach worker
18-24 Obtainedneedles/syringes fromexchange/dropin &/or
outreach worker
Moldova (IDU) Serbia (IDU) Romania (IDU) Romania (FSW) Ukraine Montenegro
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Enhanced VulnerabilityYounger cohorts have poorer
knowledge of HIV transmission and are less likely to seek formal services
Detention & harassment by police a regular event, especially for boys
Adolescent sex workers report more experience of forced sex and are less likely to use condoms consistently
Association between younger age and child protection institutionalisation
Vulnerability by Sex
Girls experience unmet need for other reproductive health, especially contraception.
Girls report higher rates of forced sex
Sex work is NOT always higher among girls
The steady partners of female IDU are more likely to also be IDU than among males.
Moving Forwards
Extending programmes that already work with IDU and sex workers – addressing overlaps
Considering links between harm reduction & child protection
Using “entry points” identified by research – i.e. willingness of adolescents to visit pharmacies
Addressing legal & institutional barriers
Next Steps: Qualitative Studies
Interviews and focus group discussions conducted in Ukraine with MARA sex workers
Formative interviews with MARA MSM, sex workers and providers in Moldova
Focus group with IDU and interviews with sex workers in Romania
Rapid assessment with IDU planned in Moldova to define intervention
Next Steps: Intervention Studies
Ukraine – frontline services for street based sex workers in Mykolaev
Romania – referral link network developed between child protection services and health providers
Moldova – peer delivered intervention to reduce injection initiation under consideration
M&E frameworks developed to guide process and output evaluations
Future Steps
Write-up of baseline results (1 paper in press)
Intervention and M&E framework developed for Moldova
Process evaluation workshop in Ukraine; qualitative data analysis
Follow up on intervention research in Romania
Extend model to other countries (?)
Lessons Learned Focused, country-specific technical
assistance more effective
In depth research in a small number of countries better than “standardised” capacity building for many countries
Regional workshops to compare study designs and results useful to national researchers
Need more than 3 years to conduct baseline, qualitative and evaluation research components