Research priority-setting: reproductive health in the occupied Palestinian territory

Policy makers today are more reliant upon evidence-based policy planning than ever before, which increases the demand for research production. To keep up with this increasing demand, it is especially important for countries with limited resources, such as the occupied Palestinian territory (oPt), to identify priority research areas in order to focus their resources on the needed evidence and reduce duplication of existing studies. This study aims to identify a list of the most important reproductive health research questions proposed by Palestinian health providers and experts. The participants included most of the stakeholders and experts in reproductive health service provision and research in the oPt. These experts identified research questions which were grouped by the researchers into common themes. These themes were further prioritized by the experts based on standardized methods. A list of 50 research questions were identified. Several questions related to the health system, including quality of care, health professionals’ knowledge and preparedness, access to and availability of services, were among the most important questions. Questions related to high-risk pregnancies and maternal mortality were also within the 50 top research questions. Few questions on adolescents’ sexual and reproductive health and gender-based violence were within the top 50 research questions. Future research should focus on the identified high priority areas. Policy makers and funders should work in coordination to ensure the production of research with value to the Palestinian context.

Around 85% of research investment worldwide is wasted as reported by Chalmers et al. A waste in research was considered, “when the need of potential user of research evidence was ignored or when available evidence was overlooked” [1]. The reasons for waste included choosing the wrong research question, conducting studies that are poorly designed, and failing to publish unusable sections of research [1]. It thus becomes imperative to set research priorities to help maximize evidence utilization and reduce research waste, especially in low-income countries with limited research resources [2].

In the occupied Palestinian territory (oPt), research is mainly conducted by academic institutions, occasionally in collaboration with health providers. Research conducted is mainly selected based on consultation with health providers, observation, and experience of the researcher in a specific field or in response to a funder and/or health provider request [3]. The number of published papers focusing on health in Palestine/oPt has increased since 2010 compared to previous years. However, only 29% of these papers were cited more than 5 times [4], which might indicate local rather than international importance. In addition, it might indicate that these studies are not addressing the right questions.

In relation to reproductive health (RH) research, a comprehensive review on maternal and child health in the oPt described the situation with respect to the fourth and fifth Millennium Development Goals on reducing child mortality and improving maternal health, respectively. The review also identified several research areas as well as reported the type of research conducted and the quality of available data [5].

Several research priority exercises were conducted to address the global, and more specifically, low and middle-income countries needs [6‐9]. However, a country-specific research priority list is imperative to help provide the needed evidence for program and intervention planning at the national level. Therefore, this study aims to build a research agenda for RH in the oPt that can be utilized by RH stakeholders and contribute to the development of policy-based evidence to guide health practice.

We used the reproductive health definition adopted by the International Conference on Population Development (ICPD) Program of Action held in Cairo in 1994. In the current study, we followed research prioritization methods developed by the World Health Organization’s (WHO) Child Health and Nutrition Research Initiative (CHNRI) [10]. The prioritization exercise was implemented in three phases: (1) the generation and collection of research questions, (2) consolidation of research questions and thematic analysis, and (3) the prioritization exercise of the research questions using pre-defined scoring criteria.

Figure 1 shows the study and analysis flow of the three phases. A total of 34 participants from 19 organizations responded positively to phase 1 invitation and provided 1239 research questions in reproductive health. After removing duplicate and out of scope questions and conducting thematic analysis, a total of 232 research questions emerged covering three main thematic areas (health systems, community-related and individual-related aspects within reproductive health). Out of the 34 participants, 30 individuals from 16 organizations partook in phase 3 scoring exercise (individual response rate of 93.8%). A list of 50 research questions was identified as priority research areas in reproductive health in the oPt.

The current study identified the national research priority areas within reproductive health in the oPt. The list is comparable to the one identified for low and middle income countries by de Francisco et al. [12]. A wide range of questions were raised, including simple epidemiology questions, health system, and social and behavioral questions. However, the list lacked specific clinical, operational, or intervention questions. As for reproductive health topics, questions related to safe motherhood were more than 50% of the questions followed by health system related questions. Adolescents health and gender-based violence questions were least mentioned. Interestingly, a greater emphasis was given to questions related to elderly women in their menopausal phase. Usually, this group is categorized within the marginalized or vulnerable groups. It is also worth mentioning that topics such as abortion and sexually transmitted infections (STI) were neither in the top 20 nor 50 priority areas. Although they were mentioned by different local experts, they did not reach enough consensuses to be ranked highly.

The process of setting research priorities in low and middle-income countries is challenging since it requires the involvement of all stakeholders to come to a national consensus. In our study, Palestinian experts and stakeholders working in reproductive health at the governmental and non-governmental sectors, universities, gynecologists, and statistical offices participated in this exercise. The challenge we faced was at the beginning of this exercise because some stakeholders did not understand the process and aim of the research priority setting and they thought it is funding priorities for reproductive health services. However, once they understood the aim and importance of the exercise, they became motivated and had almost a hundred percent response rate. This is in line with Rudan’s et al. main recommendation to improve the process of prioritization in health research by increasing the acceptability and popularity of such process with local policy makers [13].

The results of this study provide local and context-specific questions which cannot be compared to other countries specifically; nevertheless, they are in line with what has been reported by de Francisco et al. [12]. The results were general and not specific as reported in other studies since our study asked for general research questions while the other studies focused on interventions [7, 14] or specific governmental services [15]. In fact, research priority setting is an iterative process, and this is only the first step in a much longer process of refining the research priority areas into more specific questions. Hence this list should be reviewed and updated regularly. Based on the presented RPS findings, area specific research priority setting should be conducted for some topics, such as family planning and adolescents health, where validated methods were developed and used previously [6, 7, 16]. These areas were mentioned by different experts but did not reach consensus on specific questions.

The priorities were not similar across different respondents, perhaps because each was gearing the question toward their interest and experience. For example, the gynecologists were asking about unwanted pregnancies and abortion, health providers were interested in how to address cultural and norms barriers to family planning services, and other ministries were inquiring on how to improve family planning awareness and education, etc. Service providers in general were interested in understanding factors that are beyond their control, including cultural norms and beliefs, to improve their services. As for academics, in addition to understanding the quality of available health services, they were also interested in understanding the burden of selected topics locally that is of international importance. Although variation exists, the overall responses were complementary, and a comprehensive list of research priority was produced and agreed upon by all respondents.

Priority research areas in reproductive health were identified. The research priority list should be utilized by researchers, policy makers and funders to ensure that the results of the conducted research are of value to the Palestinian population and context.