Evaluation of MISP Implementation in Nepal: Training on Focus Group Discussions

1. Process Evaluation of MISP Implementation in Kathmandu and Sindhupalchok, NepalTraining: Focus Group Discussion (FGD) September 10-12, 2015 Research. Rethink. Resolve. Samira Sami, MPH DrPH CandidateJohns Hopkins University Anna Myers, MPH Research Manager Women’s Refugee Commission

2. Agenda • Day 1: Training • Introductions • Staff roles and responsibilities • Overview of the MISP • Overview of the evaluation methodology • Ethical issues and safety protocols • Overview of focus group discussions (FGDs)

3. Agenda (2) • Day 2: Training • Introduction to FGD Tools • Practice, practice, practice • Day 3: Pilot • Conduct one male and female FGD • Practice translation/transcription • Debrief

4. Introductions • What is your name? • Where are you from? • What are your favorite activities to do? • What is your research experience? • Experience in qualitative research • Experience in reproductive health research or other work

5. Staff Roles and Responsibilities

6. Structure of Evaluation Team • Site 1: Kathmandu • 1 Male Facilitator and 2 Male Notetakers • 1 Female Facilitator and 2 Female Notetakers • Site 2: Sindhupalchok • 1 Male Facilitator and 2 Male Notetakers • 1 Female Facilitator and 2 Female Notetakers

7. Roles/Responsibilities of Teams • Roles • Facilitator • Notetakers • Interpreter • Responsibilities • Timeliness • Respect • Be prepared • Team player • Ask questions!

8. Timeline of Activities

9. Timeline

10. Timeline

11. Communication Protocol • Security Issues • Administration • Hours and lateness • Housekeeping issues

12. Planning FGD Schedule and Participant Recruitment • List of health workers • How to recruit participants and informed consent • Selecting the right environment/setting • Scheduling dates/times for your FGDs

13. QUESTIONS?

14. Overview of the MISP

15. Reproductive Health in Crisis Settings • WHY do we need to pay attention to RH in a crisis? • 60% of preventable maternal deaths & 53% of child deaths occur during crisis • 4% of population pregnant at any time: • 15% of pregnant women will need emergency obstetric care • 9-15% of newborns will need live-saving emergency care • Consequences of crisis can elevate mortality and sexual violence

16. Reproductive Health in Crisis Settings (2) • How does crisis worsen reproductive health? • Destruction of health facilities • Lack of trained staff • Health facilities overwhelmed • Breakdown of social structures, families • Lack of supplies • No access (displacement, security, cultural restrictions, knowledge/attitudes towards HC, economics) • Targeted and opportunistic sexual violence • Sexual exploitation

17. What is the Minimum Initial Service Package (MISP) for Reproductive Health? • Minimum: • Ensure basic, limited reproductive health services • Initial: • For use in emergencies, without site-specific needs assessment • Service: • Health care for the population • Package: • Activities, supplies, coordination and planning

18. Research. Rethink. Resolve.

19. Objective 1: Coordinating implementation of MISP priority RH services Ensure the health sector/cluster identifies an organization to lead implementation of the MISP.

20. Objective 2: Preventing and managing the consequences of sexual violence • Putting in place measures to protect affected populations from sexual violence • Making clinical care available for survivors of rape • Ensuring the community is aware of the available clinical services

21. Objective 3: Reducing the spread of HIV • Ensuring safe and rational blood transfusions • Enforcing respect for standard precautions • Guaranteeing the availability of free condoms

22. Objective 4: Preventing maternal and newborn death and disability • Ensuring availability and accessibility of EmOC and newborn care services at health facilities and referral hospitals • Establishing a referral system • Providing clean delivery kits

23. Objective 5: Planning for Comprehensive RH Services • Collecting existing background data • Identifying suitable sites for future RH service delivery • Assessing staff capacity • Ordering equipment and supplies

24. Additional MISP Priorities • Family Planning • Sexually Transmitted Infections • Prevention of Mother-to-Child Transmission of HIV/AIDS

25. QUESTIONS?

26. Overview of Evaluation

28. Evaluation Methodology • Case study design • Kathmandu • Sindhupalchok • Purposive sampling • Population • Program staff • Health workers • Community • Methods: • Key informant interviews • Health facility assessments • Focus group discussions

29. Evaluation of the Implementation of the MISP for RH among Crisis-Affected Persons in Kathmandu and Sindhupalchok, Nepal • Purpose of FGDs • To qualitatively assess the extent that the MISP has been implemented in Kathmandu and Sindhupalchok since the earthquake • FGD Objectives • To assess the extent that RH services are available and accessible • To explore how resources (human and material) relevant to the MISP were allocated, mobilized, and delivered by agencies in the humanitarian response • To explore awareness about and use of RH services by the crisis-affected population • To explore the factors that influence the implementation of the MISP

30. Focus Group Discussions Purpose: To understand the knowledge, attitudes, and access of RH services among the crisis-affected population Group composition: no more than 10 participants per group

31. Evaluation Collaborators • Evaluation Team • Women’s Refugee Commission • Boston University School of Public Health • Johns Hopkins Bloomberg School of Public Health • RIDA research staff • Evaluation Partners • Department of Health (DOH) Nepal • United Nations Population Fund (UNFPA) Nepal • FPAN - SPRINT (Sexual and Reproductive Health Programme in Crisis and Post-Crisis Situations) • Reproductive Health Sub-Cluster in Nepal

32. Evaluation Outcomes • Share findings with evaluation partners to inform the development of program and policy recommendations • Improve reproductive health services for people affected by the earthquake in Nepal • Disseminate final report for local and international learning • Inform future emergencies by ensuring quality RH services are provided to affected populations in similar contexts

33. QUESTIONS?

34. Lunch!

35. Ethical Issues and Safety Protocols

36. Principles of Ethical Research Respect integrity & minimize harm Informed consent Confidentiality Privacy Secure handling of data Sharing results with relevant stakeholders Understand the referral pathway for gender based violence

37. Elements of Consent • * If non-literate, read slowly in appropriate language and ask for questions • Introduction • Purpose of Study • Procedures • Risks & benefits • Questions or Concerns • Confidentiality • Voluntary Participation

38. Practice: Informed Consent • Read out loud • Identify consent elements: • Purpose of Study • Procedures • Risks and benefits • Questions or concerns • Confidentiality • Voluntary Participation

39. Eligible FGD Participants • 18 and older → regular consent • 15 to 17 years: must meet one of these • Ever Married • Pregnant • Parent of a child

40. Referral Pathway for Gender Based Violence See Handout Research. Rethink. Resolve.

41. Overview of Focus Group Discussions

42. Quantitative vs. Qualitative Research • Qualitative: • Attempts to explain • Complex, changing (‘fluid’) • Describes meanings: • Perceptions, knowledge, beliefs, behaviors • Describe variation • Behaviors explained in context of what is happening around them • Quantitative: • Attempts to measure • Often can quantify an event but NOT explain why it occurred • Standardized so that larger generalizations can be made

43. Quantitative

44. Qualitative What happens in a house, how is a “home” defined, what influences what people do in their houses?

45. What is qualitative research? Qualitative research is flexible. Non-leading questions and statements are used. Information is probed as much as possible. Participants are treated as the expert. The participants lead the conversation while staying on topic. How and why things happen are of most interest. The words people use are analyzed. Research. Rethink. Resolve.

46. No ‘right’ or ‘wrong’ – we are trying to understand perceptions

47. What is a focus group discussion? A group interview that emphasizes communication among group members in order to generate information about a chosen topic

48. Why Do Focus Groups? • To collect information about knowledge, behaviors, what people think, how they think and why they think that way • To discover variety within a homogenous population • To assess areas of agreement and disagreement between groups • To develop a consensus view on a product • To empower participants, to hear their voices * FGDs: NOT a way to interview a number of people at once

49. Roles in a FGD • Facilitator - conducts the group interview • Must be able to ask and clarify a question • Hear the response • Determine if further clarity is needed regarding the responses • Notetaker- records what is being said or expressed • Responsible for ensuring detailed documentation of the FG • Back-up to recording device • Captures quotes and who is speaking • Retain specific terms or phrases in local language • Record body language and nonverbal signals of participants • Remind facilitator of issues overlooked during the discussion • Both positions need to work together

50. The Facilitator Research. Rethink. Resolve.