Using Research to Influence Sexual and Reproductive Health Practice and Implementation in Sub-Saharan Africa: A Case-Study Analysis

"Research institutions and donor organizations are giving growing attention to how research evidence is communicated to influence policy. In the area of sexual and reproductive health (SRH) and HIV there is less weight given to understanding how evidence is successfully translated into practice. Policy issues in SRH can be controversial, influenced by political factors and shaped by context such as religion, ethnicity, gender and sexuality."

The selected case studies included here were presented at a meeting on research engagement with policy and practice in SRH and HIV, which involved researchers, communication specialists, and donors working with Department for International Development (DFID)-funded SRH and HIV Research Programme Consortia. The criteria against which the case studies were chosen illustrate the role of partnerships, networking, and interaction of researchers, with both policy and practice actors in SRH research in Sub-Saharan Africa. They also illustrate the importance of long-term engagement between researchers and policymakers and how to use evidence to develop policies which are sensitive to context: political, cultural, and practical.

The authors draw on a framework that is grounded on 3 meta-domains of policy change (policy actors or networks; policy ideas and evidence; and policy context or institutions), which, used here to frame the case studies, can be divided into 2 categories determining policy outcomes: the "pre-conditions" for research use (meaning the existing policy context), and actions and interventions (or those things which increase the probability of research being used by policy actors).

The case studies focus on:

1. Syphilis screening and treatment during pregnancy in Ghana - "The researchers believed that the involvement of all stakeholders throughout research planning and design, conduct of research and result dissemination gave them ownership of the research and thus increased the likelihood of policy adaptation and implementation."
2. Influencing legislative change for sexual violence survivors in Ghana - In 2008, the INDEPTH research network in Ghana commissioned an assessment of the laws and policies governing SRH; the work, undertaken by a human rights lawyer, showed that there were deficiencies in laws and that they were not high priorities for government officials. A strategy was devised to share findings of the assessment with key stakeholders: they were shared widely with parliamentarians, regional directors of health, social services, the Commission on Human Rights and Administrative Justice, and traditional, religious, and women leaders, in the capital Accra and in two regions. Direct engagement with parliamentarians was necessary, as was respect for their limited time and the need to present them with clearly articulated approaches with which to address the legislative and policy issues. Parliamentarians, particularly those connected to the health sector, were reached through tailored communication strategies after which meetings were organised by parliamentary clerks at which solutions were presented. The presentations were made by legal advocates and researchers. At a public level, engagement took place with the media using what were intended to be compelling human stories supported by statistics to generate public interest and to raise the profile of the issues. The media were identified as important allies in complementing the parliamentary lobbying activities as a result of their coverage.
3. Introducing a national male circumcision policy into South Africa through the South African National AIDS Council - "The translation of research on male circumcision into policy has required key stakeholders to navigate a complex set of relationships and interactions. Researchers have been required to engage at all stages of this process, often beyond their traditional roles. Through broad-based consultation a deeper understanding of the benefits of male circumcision in the context of HIV prevention has been achieved and ultimately, the development of a comprehensive policy has been realised."
4. Scaling up adult male circumcision (AMC) for HIV prevention: the Tanzanian experience - "The policy development process started after evidence that emerged from trials conducted in South Africa, Kenya and Uganda showed that AMC provided partial protection against HIV infection. There was however a lack of locally relevant information required to inform the policy development process. Locally specific research was therefore undertaken as part of the situation analysis study; local research findings informed the development of the Tanzanian strategy and the planning of AMC demonstration sites. Experience gained from demonstration sites further informed the policy features....Traditional leaders play a key decision making role in circumcision and should have a role to play in the national strategy for the national programme to be successful in traditionally circumcising areas. Health systems need strengthening for effective delivery of circumcision services. NIMR [National Institute for Medical Research] presented these findings to the two oversight bodies and an implementation strategy was developed."

The "results and discussion" section of the paper presents the salient issues arising from these case studies in terms of what have been useful lessons in shaping policy uptake and/or practice. Within this approach, the authors identified the importance of how research, policy, and practice actors communicated and interacted with each other. To cite one finding: "In relation to policy change in Ghana, research use that emphasised a two-way flow of information benefited policy change whereby researchers could orientate findings to targeted policy actors and research users could adapt findings to their specific contexts. Conceptual research use that focuses on forging partnerships was seen to facilitate understanding and knowledge acquisition between research, policy and practice actors."

The authors conclude that: "The linkages and networks between stakeholders and particularly the central role of practitioners that occurred in the case-studies suggest the significance of designing networks and partnerships carefully from a project's inception. Participatory approaches and engagement strategies directed by well-connected local individuals were seen to have strong impacts in the contexts scrutinized here. Researchers and communication specialists need to work at developing networks of actors across the policy and practice continuum, while designing long-term communications strategies appropriate to a range of specific technical, political and cultural contexts. This may involve working simultaneously at conceptual and instrumental levels to connect researchers with both policy makers and practitioners."