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In-Depth Reading Time: 10 minutes

Strengthening Research Skills: Evidence-based FP and Resilience in Afghanistan

Building on the strengths of country governments, institutions, and local communities while recognizing the importance of the local leadership and ownership have been of central importance to USAID programming. The USAID-funded Data for Impact (D4I) Associate Award of MEASURE Evaluation IV, is one initiative that is a testament to the local capacity strengthening approach that appreciates the existing capacities of local actors and strengths of local systems. Introducing our new blog series that highlights local research produced with support from the D4I project, ‘Going Local: Strengthening Local Capacity in General Local Data to Solve Local FP/RH Development Challenges.’

D4I supports countries that generate strong evidence for program and policy decision making and strengthen individual and organizational capacity to conduct high-quality research. One approach to this objective is to administer a small research grants program and collaborate with local researchers to:

  1. Build and strengthen research capacity among local country organizations and agencies;
  2. Address research gaps in family planning (FP) to inform policy and programmatic decision-making; and
  3. Increase use of research findings by providing an opportunity for the data to be disseminated to and used by local stakeholders and decision makers.

Oftentimes, when articles are published about research they focus on the findings and the potential implications. However, if another country or program aims to implement a similar study, it is also equally important to document how they conducted the research, what was learned and what are the recommendations for others interested in doing similar research in their own context.

With this goal in mind, Knowledge SUCCESS has partnered with the D4I award program for a 4-part blog series featuring the tacit lessons and experiences of family planning and reproductive health (FP/RH) research conducted in four countries:

  • Afghanistan: Analysis of 2018 Afghanistan Household Survey: Understanding Regional Variations in FP Use
  • Bangladesh: Assessing the Readiness of Health Facilities for FP Services in Low-resource Settings: Insights from Nationally Representative Service Provision Assessment Surveys in 10 Countries
  • Nepal: Appraisal of FP Commodities Management during the COVID-19 Crisis in Gandaki Province, Nepal
  • Nigeria: Identifying Innovative Approaches to Increase Domestic Resource Mobilization and Financing Contributions for FP

In each post, Knowledge SUCCESS interviews a member of the research team of each country to highlight how the research addressed gaps in FP knowledge, how the research will contribute to improving FP programming in the country, lessons learned, and their recommendations for others interested in conducting similar research.

According to the 2015 Afghanistan Demographic and Health survey, the country has one of the highest maternal and infant mortality rates in the world. This is related to its low modern contraceptive prevalence rate (mCPR) at 18.4% (FP2030) and subsequent high total fertility rate (4.8 children per woman in 2020). Furthermore, the unmet need for FP among married women, 15-49 years old, in the country was 25% in 2020. These data were gathered prior to the fall of the Afghanistan government, and current data is difficult to gather due to ongoing conflict in the country.

Wanting to better understand this situation, the Organization for Research and Community Development (ORCD), an Afghanistan-based non-governmental organization founded by a group of community development and research specialists, decided to investigate the factors affecting the unmet need for modern contraceptives across the regions of the country.

In 2021, ORCD received a small grant from the USAID-funded D4I award of MEASURE Evaluation to conduct their research, Analysis of 2018 Afghanistan Household Survey: Understanding Regional Variations in FP Use. Originally, the research was also going to include qualitative data collection to determine the impact of COVID-19 on access to and use of FP, adaptations to FP service delivery approaches, and the quality of services provided during the pandemic. However, due to the sudden political crisis with the fall of the Afghan government, the research shifted to solely secondary analysis of data from the 2018 Afghanistan Household Survey. By December 2022, with technical support from D4I staff at the University of North Carolina at Chapel Hill, the Afghan research team completed and published their research despite the immense challenges they faced.

Knowledge SUCCESS talked with someone involved in the research to learn about their experiences in the midst of the sudden collapse of the Afghan government and how they quickly pivoted their research objectives and methodology.

Grace Gayoso Pasion (Gayo): What inspired you to become a researcher or to work in this area?

Key Interviewee: I was a medical doctor and I was always very interested in the public health area. Once I finished my medical degree, I started volunteering and working with some organizations where I have seen the health issues and challenges of Afghan women. Women do not have full access to basic health services. They were suffering from lack of availability and quality services. This motivated and encouraged me to go to the public health field where you could see the bigger picture rather than just dealing with one individual patient…In Afghanistan, we do not have many female experts either in public health or in the research field. We need to start from somewhere. I thought [I could] be part of that change or to be part of that team that can contribute something meaningfully towards women’s reproductive health.

Gayo: What drew you to the D4I small grants program? Why did you apply for that grant?

Key Interviewee: The country has one of the highest maternal mortality in the world…I find it quite exciting because even if the grant was very small, I [knew] that the intellectual value of the program or the impact that we could make on the issues facing Afghanistan through this grant will be very rewarding. That is why we decided to apply for this grant.

Gayo: What specific research did you conduct under the D4I small grant program? What was the goal of that research?

Key Interviewee: According to the Afghanistan mortality survey, which was conducted in 2010, around 91.6% of women of childbearing age have knowledge about any modern FP methods, but only 20% of women respondents reported using any modern method of family planning. This suggests that there is a huge gap between the knowledge and the practice of FP methods across the country. Therefore, we want to find out, through our study, the variation in FP use and the factors affecting it across all the regions…We used the Afghanistan 2018 household survey. It was a countrywide survey and there was a lot of data which was not fully utilized. We took advantage of that and we thought, “why not conduct a secondary data analysis through that available data set?”. Then, we came up with this idea to work on this part of the data which was not utilized — the variation of family planning used across the regions and the factors affecting the use of family planning.

Gayo: Initially, you had a different research objective but had to change course due to a political crisis and deteriorating security within the country. Why did you still pursue doing research and shifting to a new research objective despite these challenges?

Key Interviewee: We wanted to offer something meaningful through our research findings… [The sub-award] was granted in February 2021. The project was for a year. By the time we signed the Agreement in June or July [of that year], we started the project and got the approval from the former Ministry of Public Health of Afghanistan to conduct this research. By August, the government fell in Afghanistan. We were exactly in the middle of the project when the change happened in the country.

Unfortunately, due to the sudden change of political environment, it was no longer possible to carry out some of our research activities. We could not conduct the key informant interviews.

However, the team was really determined to complete the project regardless of the challenges. So we requested to amend the project deliverables and we carried it out until we completed the project.

This Afghanistan study found that there are significant varying degrees of modern contraceptive use among the different regions of the country. It also revealed that there is a strong connection among women’s educational level, age, and parity and contraceptive use. Findings also showed that pills and injectables were the most commonly used modern contraceptive methods while abstinence and withdrawal were the most commonly known traditional methods. The research cited health facilities as the main sources of information on contraceptives and therefore, a factor for increased use of contraceptives. Lastly, the study also suggested that TV and radio would be the best media to promote health education and the use of contraceptives given their pervasiveness in the country compared to other media sources.

Gayo: Any surprising results that you found from the study?

Key Interviewee: (Laughs) Yes. Initially, we were thinking that some regions must be lacking the knowledge about the benefits and advantages of family planning, available services, and about modern methods. However, one of the surprising results was that in one of the regions which has the highest percentage of respondents who said they knew about family planning methods and services, it also has the highest gravidity [the number of times a woman has been pregnant]… There must be other factors contributing towards that – this was unfortunately beyond our study to find out…. We could not conduct qualitative data collection so we recommend a more in-depth study to find out the other contributing external factors or reasons for this.

Gayo: Given the sudden political crisis and rapidly deteriorating security situation in the country in the middle of doing research, what challenges did you face? How did you resolve them?

Key Interviewee: When we submitted the proposal for this small grant, the situation was very normal in Afghanistan. No one was expecting that a challenging situation would unfold. Once the situation changed, the team got scattered and everyone was hiding and running…some left the country while some went to very remote areas… We did not have any office facilities and equipment like internet, electricity, computers, or printers. Everyone was just scared for their life…With no office facility, communication was also difficult. Reaching out to them [the research staff] was difficult. They could not use their mobile phones because they were scared to be tracked…Emails were also not safe so we researched for the safest option of communicating and sending documents…On top of that, we had a lot of financial problems because all the banks were frozen in Afghanistan.

“The experience built our resilience. The quote “train hard, fight easy” came true in this context because they were supposed to learn the principle of research, but they have learned it the hardest way possible.”

Key Interviewee

Gayo: how were you able to boost the morale of the staff and to proceed with the research project?

Key Interviewee: For me, as a principal investigator, it was to stay motivated regardless of the risks involved, and to think back and work through our plan. I know that one project is not going to change the entire world, but at least we could contribute something to the body of knowledge in the field.

We also share our very personal problems with each other, and I was constantly supporting them. We have also been very honest, and we just told USAID and the University of North Carolina about our problems. I think being honest is very good. If you are honest and you ask for support, there are always people willing to help you and support you.

Being flexible is another thing. We try not to be very rigid and we try to find a way how we can make it work. I believe that worked very well for all of us.

One of our staff was under very serious threat during that time. They were on the run and hiding. For a time, they were not mentally available to do anything because they were very scared for their family’s safety. I stepped in and I said, “I’m going to do this so you don’t have to worry about that.” But they said, “No, I committed myself towards this project, and I would like to contribute towards something meaningful. I will do it. Just give me a little bit of time until I get mentally settled with the situation.” So that is why we extended the project and we gave them time to do that. I did not want to take that ownership from them by stepping in and doing it myself.

Gayo: In what ways do you think your research can help with the FP/RH program in your country? How do you see your research being used in the field of FP?

Key Interviewee: With the changing political situation in Afghanistan, it is a bit difficult at the moment to be honest. But I am very hopeful that the recommendations we shared to the Ministry of Public Health and all the other international organizations are still working in Afghanistan somehow… Change is not going to happen overnight… they need to make sure that they take all these recommendations into account — to increase the use of family planning methods, to decrease the fertility rate, and to improve the maternal child and reproductive health services in the long term.

The study provided the following recommendations:

  • Using a multisectoral approach, the Ministry of Public Health, Ministry of Education, and Ministry of Information and Culture should collaborate, and with key involvement of religious leaders, initiate the most effective and efficient ways to educate and raise awareness about FP benefits and methods.
  • Use TV and radio campaigns across the country to increase knowledge about FP use, advantages, methods, and accessibility given they are the main means of disseminating information in Afghanistan.
  • With health facilities playing an important role in raising awareness and increasing modern FP use, high-quality FP services should be available and accessible across all regions, specifically in regions with lower use of modern contraceptives.
  • Considering the political and cultural context of Afghanistan, reproductive health programs should engage private clinics, pharmacies, community midwives, and community health workers, among other stakeholders, to encourage the use and benefits of modern contraceptives, especially in rural areas.

Gayo: Your research has helped FP/RH programs. How about for you and your team, what skills have you gained through conducting this research?

Key Interviewee: The team learned how to communicate well and how to do the literature reviews. I was here in the UK and my staff were there. They did not have any means to find literature related to the study. Some of the staff were very keen to learn because when I told them that I will do the literature review, they said, “No, we have to learn this because this project is for capacity building of the local staff so we would like to do it.”

They also learned coding by simply tinkering around with the software used for analysis. Coding was not easy for them because they have never worked on that before. Now, at least they learned the basics — how to use the software, how coding is used, the purpose of coding, how to enter the data, and how to interpret the data.

They also learned about methodology — how it works, how to do it, how to come up with a research idea, how to structure research proposals, and how to make the research questions. They were very keen to learn and some of them plan to continue doing research.

The ORCD is also still a very young organization. This project gave them a very golden opportunity — all the local staff were directly involved and they contributed a lot toward this research project. Usually, expatriates conduct the research in Afghanistan, but in this project, the Afghans, the local community, took full ownership of that.

“Usually, expatriates conduct the research in Afghanistan but in this project, the Afghans, the local community, took full ownership of that.”

Key Interviewee

Gayo: What lessons did you learn along the way, given the situation that you are in, that could be useful for other researchers or program implementers who might be experiencing the same situation right now or could possibly experience it in the future?

Key Interviewee: The experience built our resilience. The quote “train hard, fight easy” came true in this context because they were supposed to learn the principle of research, but they have learned it the hardest way possible. Moving forward, I think it is going to remain with them for the rest of their lives.

Lessons learned in doing research within conflict-affected areas:

  1. Stay positive and motivated. Look forward to how your findings could create meaningful impact to the country or the community.
  2. Be flexible. Find a way to make things work given the challenging situation.
  3. Keep communication open among team members. Be compassionate, understanding and sensitive to team member’s situations and problems.
  4. Be honest with donors. Share your challenges with them and ask for support.
  5. Have a good plan at the start. A good plan will save the project when something unexpected happens.

Gayo: I am sure people are fortunate to have someone like you and your team who are providing meaningful impact in whatever way you can to help Afghanistan. Thank you for your time. Anything else that you would like to share with us?

Key Interviewee: Special thanks to my team in Afghanistan who were really the champions. All of them were heroes — they were able to manage this project in a very difficult time. They are an inspiration for everyone. I am sure that researchers or those people who are working on their research projects in conflict-affected countries, can get inspiration from the team, and from this experience. They should never give up. Be motivated and see the bigger picture rather than just the temporary problems or challenges ahead of them. Build their resilience.

Grace Gayoso Pasion

Regional Knowledge Management Officer, Asia, Johns Hopkins Center for Communication Programs

Grace Gayoso-Pasion is currently the Asia Regional Knowledge Management (KM) Officer for Knowledge SUCCESS at the Johns Hopkins Center for Communications Program. More known as Gayo, she is a development communication professional with nearly two decades of experience in communication, public speaking, behavior change communication, training and development, and knowledge management. Spending most of her career in the nonprofit sector, specifically in the public health field, she has worked on the challenging task of teaching complex medical and health concepts to urban and rural poor in the Philippines, most of whom never finished primary or secondary school. She is a longtime advocate for simplicity in speaking and writing. After completing her graduate degree in communications from Nanyang Technological University (NTU) in Singapore as an ASEAN scholar, she has been working in regional KM and communication roles for international development organizations assisting various Asian countries with improving their health communication and KM skills. She is based in the Philippines.