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Most at Risk Adolescents in Eastern Europe Building the Evidence Base. Joanna Busza & Megan Douthwaite London School of Hygiene & Tropical Medicine September 2, 2009. LSHTM approach to technical assistance .

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most at risk adolescents in eastern europe building the evidence base

Most at Risk Adolescents in Eastern EuropeBuilding the Evidence Base

Joanna Busza & Megan Douthwaite

London School of Hygiene & Tropical Medicine

September 2, 2009

lshtm approach to technical assistance
LSHTM approach to technical assistance
  • 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.
technical assistance proposed structure
Technical Assistance Proposed Structure
  • Regional training & study design workshops
  • Development of standardised tools
  • Guidance on country-specific issues
  • Data analysis workshops
  • Country visits for specified activities
  • Distance based backstopping & advice

Synthesise available data

Analyse costs and effects; Follow-up survey (?)

Identify knowledge gaps on MARA

Process evaluations(3 countries)

Select local sample populations & recruitment strategies

Develop interventions

Collect data on risk & protective behaviours(7 countries)

Explore context & dynamics (4 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 …

Choosing the right methodology is a logical process, with several decision-making steps

designing baseline studies
Designing Baseline Studies
  • What data on MARA already exists?
  • Who has contact with target groups?
  • What are the advocacy objectives?
  • What are plans/ goals for interventions?
  • What is the main purpose for the evidence produced?
risk vs vulnerability
Risk vs. Vulnerability

Assess & profile % of most-at-risk populations who are adolescents?


Determine & characterise % of specific adolescent groups who are involved in risk behaviours?

eco social framework for risk
Eco-social framework for Risk





Peer norms &Networks

Available services



Risk perception



Local Environment



Cultural attitudes & expectations

research components
Research Components

Sample selection

Development of instruments

Adaptation to country-specific contexts

Addressing ethical issues

Data analysis and interpretation

Qualitative studies in select countries to explore specific dimensions of MARA experience

Intervention research in 3 countries to evaluate & cost MARA-targeted services

research trajectory
Research Trajectory


Data Collection



Compile & interpretexisting data

Identify information gaps

Design study

Select sampleand tools

Train team

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

Use appropriatefieldworkers

Monitor qualityduring research

Collect informationfrom multiple sources

Manage ethical &logistic issues

sampling mara
Sampling MARA

Venue based

Institution based

Chain Referral

Respondent Driven Sampling

Network recruitment

Snowball sampling


Combined sampling approaches

developing indicators
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
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
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

Diversity of Study Populations & Methods
lshtm analysis
LSHTM Analysis

Analysis conducted for 6 data sets

  • Romania FSW
  • Romania IDU
  • Serbia IDU
  • Moldova IDU
  • Montenegro Roma
  • Ukrainian street children
lshtm analysis22
LSHTM Analysis

Standardisation across data sets

Age range limited to 15-24EXCEPT 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 quality
Data Quality
  • Strengths - Relatively good quality re: internal consistency within data sets
  • Weaknesses - 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
  • 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
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
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
Knowledge by Age

















service use by age
Service use by Age
















enhanced vulnerability
Enhanced Vulnerability
  • Younger 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 sex39
Vulnerability by Sex
  • Girls experience unmet need for other reproductive health, especially contraception.
  • Girls report higher rates of forced sex
  • Sex work is NOTalways higher among girls
  • The steady partners of female IDU are more likely to also be IDU than among males.
moving forwards
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
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
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
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
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
Striking a balance….

Regional standardisation

Countryspecific priorities

Feasible in programmetimeframe

Scientific rigour

Data for monitoring

Data for policy advocacy

Shared learning

Tailored support