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4. THE RESEARCH PROGRAMME |
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The activities within the research programme form constituent parts of the capacity-building purposes of the overall project while also aiming more specifically at the production of knowledge which will enable programme managers and policy makers in Vietnam to address reproductive health problems in more sustained ways. The research study will be conducted in Quynh Luu district of Nghe An province over a period of ten to fifteen years. The long‑term research perspective has the benefit of enabling the research to document changes over time in reproductive health status, general living conditions and in health sector and other social sector responses to reproductive health problems. This is particularly valuable in the current socio-economic situation where rapid social transformations are taking place, fundamentally affecting the livelihoods and health status of Vietnamese people. 4.1. Research Objectives In order to contribute to efforts to operationalize and implement the concept of reproductive health, the research component of the project aims to generate knowledge of the interlinkages between reproductive health problems and their wider social context, including both the health care system and the local social, economic, and cultural conditions in which reproductive health issues are embedded. The immediate research objectives include: · Reviewing existing reproductive health research and identifying priority topics for future research, · Assessing local reproductive health needs as defined by individuals and community groups, · Collecting baseline and follow-up information on core reproductive health indicators on a periodic basis, · Measuring prevalence patterns and risk factors for a selected number of reproductive health conditions, · Examining the functioning of the health care system in regard to specific reproductive health problems, · Examining relations between policy and practice in reproductive health, · Ensuring links to the users of research throughout all research stages. 4.2. Research Location The research will be conducted in Quynh Luu district, Nghe An province. Nghe An is located in North Central Vietnam, 300 kilometers South of Hanoi. The province borders Thanh Hoa province in the North, Laos in the West, Ha Tinh province in the South and the South China Sea in the East. Nghe An is known for its capricious climate and harsh and difficult living conditions. Summers are hot and humid, winters are extremely cold, and nearly every year the province suffers substantial economic losses due to typhoons, floods, and prolonged droughts. In addition to these difficult climatic conditions, the province still suffers from the consequences of over 30 years of continuous wars which have seriously damaged its infrastructure. Despite the poverty of its people, Nghe An is known for its long-standing traditions of learning and literacy. Several revolutionary leaders were born in the province, and in the course of history many peasant uprisings and worker's strikes have taken place in Nghe An. Nghe An covers an area of 16,381 km2 of which two thirds are hills and mountains. Administratively the province is divided into 17 districts which include a diversified geographical blend of coastal, delta, midland, and mountainous areas. Arable land is limited and population pressure is high on the available land. In the plains and coastal areas, population density is up to 851 persons/km2 and the average cultivated plot per person is very small. Still, agricultural activity is the main source of income, with approximately 61% of the employed population working in the agricultural sector. In the delta areas, cultivation of rice is predominant. In addition to agriculture, the main economic activities include forestry, services, commerce, industry and aquaculture. The North Central Coast area is one of the poorest in the country. In the 1993 National Poverty Survey, nearly 30% of the total population in this region were categorized as "poor" or "very poor", i.e. having income levels below 6 US $/month. Nghe An has a total population of 2.7 million people belonging to seven different ethnic groups. The Kinh comprise 85% of the population, while other ethnic groups include the Mong, the Muong, and the Thai. The provincial capital is the city of Vinh which has a population of 210,000 people. Buddhism is the predominant religion in the province, but there is also a significant Catholic population. The moral ideology of Confucianism is strong and there is a marked preference for sons, especially in families living by fishing. The total fertility rate in the province is 4.6, and the contraceptive prevalence rate is 67%. The health situation in the province reflects the socio-economic conditions. Many people suffer from chronic poor health due to malaria, diarrhea and respiratory diseases, and the nutritional status of women and children is poor. However, due to a lack of reliable health data, it is currently impossible to assess either the health situation in general or the magnitude and character of reproductive health problems such as induced abortions, RTIs/STIs, infertility, or maternal and infant mortality and morbidity. The basic health care system is well developed, with commune health centers in almost every commune. Many centers, however, are poorly equipped and lack qualified staff: in 1997 Nghe An had a ratio of 2.6 doctors per 10,000 persons, as compared to the national average of 4.3. Nghe An has been chosen as research site for several reasons. First, it is a province with broad socio-cultural variation and a wide range of different living environments including both urban, coastal, mountainous and delta areas. This provides rich opportunities for comparative studies of the social and cultural contexts through which reproductive health problems and practices are shaped. Second, it is an area of Vietnam in which very little reproductive health research has been carried out and where more knowledge of reproductive health issues is urgently needed for policy and programme purposes. Province authorities have expressed a clear interest in more sustained reproductive health research efforts and a willingnes to cooperate with the present project (cf. attached letter of interest). Third, Nghe An is one of the provinces included in Danida's fisheries sector programme in Vietnam. An important aim of the fisheries sector programme is to improve the living conditions of poor groups in the population, with a view particularly to women's situation and opportunities. These objectives are most directly addressed by the programme's second component: Support to Freshwater Aquaculture (SUFA) to which the present project will be connected. In this context, the research project's longitudinal assessments and monitoring of basic socio-economic and reproductive health trends will provide the fisheries sector programme with general information on the changing livelihoods of local populations as well as more specific insights into the social and cultural dynamics which underlie manifest patterns of gender imbalances and economic disparities. In the first phase, project activities will be carried out in Quynh Luu district. In the next project phase, the extension of the project into a second district of Nghe An province, e.g. a mountainous district populated by minority people, will be considered in order to increase insights into the social and cultural diversity characterizing reproductive health issues. In order to maintain strong links between project activities and local partners, the vice‑chairman of the Provincial Committee for Population and Family Planning (PCFP) has agreed to function as local project coordinator. The local coordinator will be responsible for project activities at commune, district and provincial levels, ensuring connections to other social sectors and organizations, and setting up workshops with participants from health, population, and other social sectors at district and provincial levels. In addition to this, a local project assistant will be recruited from the PCFP's family planning section. A field office will be established within the PCPF and equipped with furniture and communication facilities. 4.3. Research Stages Research activities are divided into three stages. Stage I research is mainly descriptive in character; Stage II research is largely analytical; and Stage III activities are practical and policy‑oriented. Research activities will be initiated by a three months preparatory research stage in which project activities are prepared and planned by the involved researchers. Activities in this stage include: · Establishment of organizational structures and office facilities for the project, · Review and building of a database of existing reproductive health research, · Preparation of research instruments for stage I research. In recent years, a fair amount of research has been carried out on reproductive health issues in Vietnam. Yet many research reports remain unpublished and are difficult to access, and there is often considerable overlap in the research conducted while significant gaps in knowledge remain. In order to be able to draw on existing knowledge and to avoid duplication of earlier work, a review of existing reproductive health research is therefore needed. The review will be carried out by building a searchable database of existing research in reproductive health which can be expanded and updated throughout the project period. On the basis of the review, nation-wide priority topics for reproductive health research will be identified and stage I activities initiated. The review of reproductive health research will be coordinated with on-going efforts to develop an Essential National Health Research strategy for Vietnam. 4.3.1. Stage I: Collecting Basic Reproductive Health Data Activities within this stage provide basic community and reproductive health information and an initial assessment of reproductive health needs as defined by groups and individuals in the districts. The information gathered will serve as a baseline for comparisons and monitorings of reproductive health trends over time; as the basis for identification of issues in need of further research; and as a knowledge base and sampling frame for further in‑depth studies. Stage I research will take place within a time frame of six months and include the following activities: 1. Reproductive health profile A baseline reproductive health survey will be implemented to provide a broad range of information on reproductive health issues. The survey will include information on aspects of reproductive health conditions as well as insights into local knowledges and practices related to reproductive health. The baseline survey will be repeated on a periodic basis in order to monitor trends in reproductive health status over time. 2. Community profile A community profile will be drawn up from existing socio-economic data, including commune and district statistics, and from structured interviews with local key informants. The profile will particularly emphasize gender aspects of socio-economic variables. 3. Health systems profile The health systems profile will include basic descriptions of the structure and functioning of the public and private health care system at commune and district levels, available statistics on utilization of services, and outlines of existing national and provincial reproductive health policies. The profile will be based on key informant interviews, assessments of commune health clinic and district hospital statistics, and reviews of policy documents. 4. Qualitative study of reproductive health needs In order to generate an understanding of the concept of reproductive health at the community level and to facilitate links of collaboration with local communities, local perceptions of reproductive health and reproductive health needs will be studied using qualitative methods such as participant observation, rapid assessment, in‑depth interviews and focus group discussions. The study will involve different individuals and groups with the community, as well as health workers and other community workers (in sectors such as education, social welfare, and finance) at commune and district levels. Outputs of stage I research activities: Research results will be written up in the form of a research report which will be disseminated to relevant parties. In order to place local research findings in a national perspective, results of the district level research will be related and compared to the findings from the nation-wide review of reproductive health research. The stage I research report will be presented and discussed at a cross‑sectoral workshop involving community representatives and district and provincial level service providers, programme managers and policy‑makers. Besides reporting and discussing research findings, the aim of the workshop will be to link research results to other relevant programme and policy issues and to identify priority research themes for the next research stage. 4.3.2. Stage II:Investigating Selected Reproductive Health Issues Stage II research will be conducted over a period of approximately twenty-one months and constitutes the core of the research programme. This research stage comprises a series of detailed sub-studies of a limited number of reproductive health conditions selected on the basis of stage I findings. These studies aim to provide in‑depth inter‑disciplinary insights into reproductive health issues, taking into account their social as well as health systems dimensions. Examples of possible topics for research are: reproductive tract infections, sexually transmitted infections including HIV/AIDS, induced abortions, maternal mortality, ante-natal care, domestic violence, and infertility. Ideally, each study will be carried out by a team of one researcher with a social science background and one researcher with a background in the health sciences. As far as possible, the sub-studies will be conducted as integrated elements of Master's or Ph.D. studies. Detailed research designs will be prepared by the responsible research teams, but each study should comprise both epidemiological, health systems, and social science perspectives. The following subtopics will be covered: 1. Reproductive health conditions: Prevalence patterns and risk factors Community‑based epidemiological studies will be conducted of the selected reproductive health conditions in order to determine their local magnitude, distribution, and risk factors. Research methodologies may include reviews of health service statistics, cross‑sectional surveys, case‑control or cohort studies, and clinical research. 2. Reproductive health issues in a health systems context In order to assess how reproductive health needs are met, studies of relevant aspects of health system organization, utilization, and quality of care will be conducted. The research will include both public and private health care institutions and practitioners, as well as home-based health care activities. Particular attention will be paid to the relations between policies and practices in reproductive health and to the impact of national and provincial policies at the local level. Methodologies to be employed include situational analyses; interviews with health care providers, programme managers, and policy makers; observations of patient‑provider interactions; and in-depth interviews with both users and non-users of services. 3. The social dimensions of reproductive health problems Since reproductive health problems go far beyond the health care system, in‑depth studies will be carried out of the social dimensions of reproductive health. The research will explore local perceptions of reproductive health problems, their aetiology and treatment, and study the social, cultural and political contexts in which reproductive health problems are embedded. Emphases will be placed on the interconnections between reproductive health and social factors such as gender inequality, poverty, and marginalization and on the relations between reproductive health and cultural values and norms. Particular attention will be paid to social variations, depending on age, gender, social class, urban/rural contexts, etc., in experiences and perceptions of reproductive health problems. Research methodologies will include participant observations, in-depth interviews, PRAs, and focus group discussions. Outputs of stage II research activities: The results from this research stage will be written up and published as a series of reports which will be used as the foundation for stage III activities. Some studies will be published as Masterís or Ph.D. theses. Both theses and reports will be made available to local communities and authorities as well as national level programme managers, policy‑makers, researchers, and donors. 4.3.3. Stage III: Translating Research into Practice Activities within this stage aim to disseminate the research findings generated during stages I and II and to support the formulation of action plans and interventions to address identified reproductive health needs and problems. Stage III activities will be carried out within a time frame of six months and include the following: 1. Workshops at local and national levels In order to disseminate and discuss results of the research, a series of cross-sectoral workshops will be held at provincial and national levels. Workshop participants will include representatives of mass organizations (e.g. the Women's Union and the Youth Union), community workers from health and other social sectors, programme managers, policy makers, donor representatives, and researchers. The workshops will aim at the generation of ideas and suggestions for possible solutions to the identified needs and problems in reproductive health. Besides health systems development, solutions might include activities in sectors such as education, social welfare, law, finance, or fishery. On the background of workshop results, a list of recommendations for multi‑sectoral policies and programmes in reproductive health will be drawn up. 2. Plans for follow‑up research and interventions Starting from the recommendations put forward during workshops, an activity plan for phase II research will be made. Research activities in this phase may include follow‑up baseline studies; in‑depth studies of reproductive health issues not previously dealt with; or intervention studies which address issues and problems identified during phase I. The extension of the project into a second district of Nghe An province will be considered and planned. 4.4. Research Ethics Reflecting on the ethics of research and finding ways to maintain high ethical standards will be integral elements of both the research and training components of the project. Reproductive health research poses ethical challenges in several ways. At an interpersonal level it deals with issues that are highly sensitive and central to personal feelings of autonomy and bodily integrity. At a socio-political level it involves matters that are central to the distributions of social burdens and benefits and to the organization of political power and influence. At the interpersonal level, particular attention will be paid to the autonomy and integrity of persons involved in the research. In order to ensure that participation in the research is fully voluntary, research participants will be thoroughly informed about the objectives, methodologies, and uses of the research and it will be emphasized that participation in the research project is entirely voluntary. Informed consent will be sought from all research participants. In the substudies of selected reproductive health conditions, treatment will be facilitated for research participants who are diagnosed with gynecological diseases (RTIs/STIs). At the socio-political level, particular attention will be paid to the social relevance and use of the research. Efforts to ensure that research is followed up by action and intervention are part of the ethical obligations of researchers and form integral elements of the research project. Ethical clearance of the research will be sought from relevant authorities in Vietnam.
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