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

Baseline Studies:

Preliminary Results

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

Example RDS sample

Sample Populations: SW

Recruitment Reached

Albania Convenience 25

Romania Venue-based/

snowball

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

Sample sizes & gender distribution

Age distribution

Injecting Drug Use

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 Risk Profile

Condom Use with different partners

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.

Use of Services

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.

Contextual Factors

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

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

Striking a balance….

Regional standardisation

Country specific priorities

Feasible in programmetimeframe

Scientific rigour

Data for monitoring Data for policy advocacy

Shared learning Tailored support