Effects of COVID-19 on sexual and reproductive health services access in the Asia-Pacific region: a qualitative study of expert and policymaker perspectives.

The COVID-19 pandemic has strained health systems globally, with governments imposing strict distancing and movement restrictions. Little is known about the effects of the COVID-19 pandemic on sexual and reproductive health (SRH). This study examined perceived effects of COVID-19 on SRH service provision and use in the Asia-Pacific region. We conducted a qualitative study using semi-structured interviews with 28 purposively sampled SRH experts in 12 Asia-Pacific countries (e.g. United Nations, international and national non-governmental organisations, ministries of health, academia) between November 2020 and January 2021. We analysed data using the six-stage thematic analysis approach proposed by Braun and Clarke (2019). Interviewees reported that COVID-19 mitigation measures, such as transport restrictions and those that decreased the availability of personal protective equipment (PPE), reduced SRH service provision and use in most countries. SRH needs related to service barriers and gender-based violence increased. Systemic challenges included fragmented COVID-19 response plans and insufficient communication and collaboration, particularly between public and private sectors. SRH service-delivery challenges included COVID-19 response prioritisation, e.g. SRH staff task-shifting to COVID-19 screening and contact tracing, and lack of necessary supplies and equipment. Innovative SRH delivery responses included door-to-door antenatal care and family planning provision in the Philippines, online platforms for SRH education and outreach in Viet Nam, and increasing SRH service engagement through social media in Myanmar and Indonesia. To ensure continuation of SRH services during health emergencies, governments should earmark human and financial resources and prioritise frontline health-worker safety; work with communities and the private sector; and develop effective risk communications.

Health system evaluation in conflict-affected countries: a scoping review of approaches and methods.

INTRODUCTION: Strengthening health systems in conflict-affected settings has become increasingly professionalised. However, evaluation remains challenging and often insufficiently documented in the literature. Many, particularly small-scale health system evaluations, are conducted by government bodies or non-governmental organisations (NGO) with limited capacity to publish their experiences. It is essential to identify the existing literature and main findings as a baseline for future efforts to evaluate the capacity and resilience of conflict-affected health systems. We thus aimed to synthesise the scope of methodological approaches and methods used in the peer-reviewed literature on health system evaluation in conflict-affected settings. METHODS: We conducted a scoping review using Arksey and O'Malley's method and synthesised findings using the WHO health system 'building blocks' framework. RESULTS: We included 58 eligible sources of 2,355 screened, which included examination of health systems or components in 26 conflict-affected countries, primarily South Sudan and Afghanistan (7 sources each), Democratic Republic of the Congo (6), and Palestine (5). Most sources (86%) were led by foreign academic institutes and international donors and focused on health services delivery (78%), with qualitative designs predominating (53%). Theoretical or conceptual grounding was extremely limited and study designs were not generally complex, as many sources (43%) were NGO project evaluations for international donors and relied on simple and lower-cost methods. Sources were also limited in terms of geography (e.g., limited coverage of the Americas region), by component (e.g., preferences for specific components such as service delivery), gendered (e.g., limited participation of women), and colonised (e.g., limited authorship and research leadership from affected countries). CONCLUSION: The evaluation literature in conflict-affected settings remains limited in scope and content, favouring simplified study designs and methods, and including those components and projects implemented or funded internationally. Many identified challenges and limitations (e.g., limited innovation/contextualisation, poor engagement with local actors, gender and language biases) could be mitigated with more rigorous and systematic evaluation approaches.

Community engagement in health systems interventions and research in conflict-affected countries: a scoping review of approaches.

BACKGROUND: Healthcare research, planning, and delivery with minimal community engagement can result in financial wastage, failure to meet objectives, and frustration in the communities that programmes are designed to help. Engaging communities - individual service-users and user groups - in the planning, delivery, and assessment of healthcare initiatives from inception promotes transparency, accountability, and 'ownership'. Health systems affected by conflict must try to ensure that interventions engage communities and do not exacerbate existing problems. Engaging communities in interventions and research on conflict-affected health systems is essential to begin addressing effects on service delivery and access. OBJECTIVE: This review aimed to identify and interrogate the literature on community engagement in health system interventions and research in conflict-affected settings. METHODS: We conducted a scoping review using Arksey & O'Malley's framework, synthesising the data descriptively. RESULTS: We included 19 of 2,355 potential sources identified. Each discussed at least one aspect of community engagement, predominantly participatory methods, in 12 conflict-affected countries. Major lessons included the importance of engaging community and religious leaders, as well as people of lower socioeconomic status, in both designing and delivering culturally acceptable healthcare; mobilising community members and involving them in programme delivery to increase acceptability; mediating between governments, armed groups and other organisations to increase the ability of healthcare providers to remain in post; giving community members spaces for feedback on healthcare provision, to provide communities with evidence that programmes and initiatives are working. CONCLUSION: Community engagement in identifying and setting priorities, decision-making, implementing, and evaluating potential solutions helps people share their views and encourages a sense of ownership and increases the likely success of healthcare interventions. However, engaging communities can be particularly difficult in conflict-affected settings, where priorities may not be easy to identify, and many other factors, such as safety, power relations, and entrenched inequalities, must be considered.

Engineering stromal heterogeneity in cancer.

Based on our exponentially increasing knowledge of stromal heterogeneity from advances in single-cell technologies, the notion that stromal cell types exist as a spectrum of unique subpopulations that have specific functions and spatial distributions in the tumor microenvironment has significant impact on tumor modeling for drug development and personalized drug testing. In this Review, we discuss the importance of incorporating stromal heterogeneity and tumor architecture, and propose an overall approach to guide the reconstruction of stromal heterogeneity in vitro for tumor modeling. These next-generation tumor models may support the development of more precise drugs targeting specific stromal cell subpopulations, as well as enable improved recapitulation of patient tumors in vitro for personalized drug testing.

"Ten years of war! You expect people to fear a 'germ'?": A qualitative study of initial perceptions and responses to the COVID-19 pandemic among displaced communities in opposition-controlled northwest Syria.

BACKGROUND: Response to the COVID-19 pandemic has challenged even robust healthcare systems in high-income countries. Syria, a country experiencing protracted conflict, has the largest internally-displaced population globally with most displaced settlements in opposition-controlled areas governed by local and international NGOs. This study aimed to explore community perspectives on challenges and potential solutions to reduce COVID-19 transmission among displaced communities in opposition-controlled Northwest Syria. METHODS: We used a qualitative study design, conducting 20 interviews with displaced Syrians in opposition-controlled camps in Northwest Syria between April-May 2020 and ensuring over half our interviewees were women. We analysed data thematically. RESULTS: Participants described already difficult camp conditions that would be detrimental to an effective COVID-19 response, including household crowding, inadequate sewerage and waste management, insufficient and poor-quality water, and lack of cleaning supplies. Participants most frequently mentioned internet as their COVID-19 information source, followed by NGO awareness campaigns. Men had access to more accurate and comprehensive COVID-19 information than women did. Isolating (shielding) high-risk people within households did not appear feasible, but participants suggested 'house-swapping' approaches might work. While most participants had sufficient knowledge about COVID-19, they lacked practical tools to prevent transmission. CONCLUSION: This study is the first to explore perspectives and lived experiences of internally-displaced Syrians in the weeks prior to the COVID-19 epidemic in Northwest Syria. The challenging living conditions of internally-displaced people in Syria are further threatened by the spread of COVID-19. Tailored control measures are urgently needed to reduce COVID-19 transmission in camps.