Reported barriers to and facilitators of the delivery of SRH interventions
| Barriers | |
| Security | Being in an insecure environment was often mentioned as a hindrance to the delivery of interventions. Health facilities are destroyed, patients are unable to access clinics or clinics are understaffed. |
| Logistics | Damage to the infrastructure resulting from conflict impeded the operational capacity of healthcare services, difficulties securing transport (fuel and cars) especially when camps are far. |
| Lack of funding | Limited funding was also noted as a barrier, for example, for family planning programming. |
| Lack of resources | Shortages of supplies/resources (medicine and diagnostic tests) during conflict were also noted as barriers. In a study by von Roenne et al 28, it was noted that district health services were reluctant to provide contraceptives and STI drugs to a local NGO providing services to refugees due to a delay in reimbursement of services delivered to refugees by UNCHR. |
| Population movement | The continuous population movement limits both delivery and access to health services. |
| Staff affected by conflict/not buying in | Health services were also limited as staff are also affected by displacement and security concerns. Health workers did not see some health interventions as important. |
| Lack of skilled/trained health workers | The limited training of health workers was a major barrier in the delivery of interventions such as contraception provision or HIV management. This barrier was noted mostly when it came to providing contraceptives, such as LARCs. In one study, the limited availability of male medical staff was also noted as a barrier for male victims seeking care for sexual assault.31 |
| Limited services | Conflict reduces the range of available services. Other factors that were noted to affect interventions such as community mobilisation were poor network coverage/phone charging facilities. Prolonged conflict was also noted as a barrier, as services and support tend to diminish the longer a conflict goes on.32 |
| Limited movement for the women/cost barriers | Conflict reduces means of generating income, especially during displacement. Therefore, the cost of getting health services might be weighed against other priorities. In some instances, subsidisation for health services by UNHCR was still not enough.33 |
| Social norms/stigma | This was noted as a barrier for both patients as well as healthcare workers. For example, for HIV management, as there is always a lot of stigma associated with it, healthcare workers may not offer all available services or see it as a priority,34 while patients may not seek care. Same barrier was apparent for family planning provision (West, 2016). Refugees may also be stigmatised by their hosts.32 |
| Facilitators | |
| Collaboration | Multistakeholder collaboration between international NGOs, the Ministry of Health and existing district health offices/public sector were noted as facilitators. Working with local NGOs was also a facilitator as they are already connected to the community |
| Availability of funding/resources | Having adequate funding allowed for more resources. In one example, the provision of portable CD4 machines by the UNHCR improved treatment quality.35 |
| Early preparation | Having a contingency plan for times of disruption and being able to rapidly respond to a conflict were also noted as facilitators, especially for interventions that suffer if disrupted such as antiretroviral therapy (ART) provision.36 37 |
| Use of existing infrastructure | Using the existing infrastructure facilitated the delivery of interventions.38 Having a stable government, if the conflict is limited to one region, was shown to be a facilitator as it may allow for more organised and consistent services.14 |
| Improved systems/innovations | Improving systems such as integrating different activities (nutrition, medical and psychosocial) was a facilitator. Using Geographic Information System (GIS) technology with a mobile clinic was effective in delivering SRH services to IDPs.27 Creating safe spaces for girls and women within camps allowed for the delivery of family planning, maternal health and assistance to GBV victims.39 |
| Staff training | Training improved the skills of health workers and increased motivation. Continuous supervision/refresher training was encouraged. It was also shown that some mental health interventions for GBV can easily be provided if staff receive training.24 40 Tran et al41 introduced the Sexual and reproductive health Clinical Outreach Refresher Training (S-CORT) modules, an innovative approach that focuses on training on the clinical services included in the MISP. |
| CHWs involvement/outreach workers | Community health workers were seen as trusted members of the community and were useful in delivering interventions such as contraception provision and education on GBV. They were also seen as links between patients and the health system for GBV services.42 |
| Community engagement/outreach | Engaging the community through activities such as social mobilisation, empowerment and enabling strategies was a very common facilitator especially as it builds trust. Some approaches used were theatre/drama groups,18 and radio broadcast messages.43 Peer education was also another strategy used to engage the community or in small groups to address issues such as sexual assault.44 |
| Culture/context appropriate | Interventions that were specific to the context and the culture were seen to be more beneficial and as effective even for interventions that were are legally restricted such as abortions.45 A study by Wayte et al46 also found it was necessary to modify guidelines to the local context. |
| Good leadership/civic/religious leader involvement | Meeting with religious and community leaders were important for building trust and for getting permission to initiate certain interventions that may be innovations, such as CHWs delivering injectable contraceptives, 15 or introducing programming for adolescent girls.39 |
| Refugee participation | Refugee participation was noted as a facilitator as it provided manpower and community leadership.47 Refugee services run by refugees28 were shown to be feasible if there is sustained funding and technical assistance. |
| Male involvement | Interventions that involved both women and men had better outcomes and more reductions in inter-partner violence (IPV).48 |
CHWs, community health workers; IDPs, internally displaced persons; LARCs, long-acting reversible contraceptives; MISP, Minimum Initial Service Package; NGO, non-governmental organisation; SRH, sexual and reproductive health; UNHCR, United Nations High Commissioner for Refugees.