Knowledge, evidence, practice and power

Reflecting the vision and mission of Reproductive Health Matters, the current issue on knowledge, evidence, practice and power comes at a time when we are reviewing RHM’s role as a broker of knowledge. We aim to build on its success and further explore the organisation’s potential to engage in international dialogue on sexual and reproductive health and rights research, policy and practices, promoting evidence- and rights-based responses. Thus, it is timely to take the opportunity that this theme provides to reflect on the importance of knowledge creation, how we can promote the generation of relevant and robust evidence and examine the barriers and opportunities to deliver evidence-informed policies and practice within a human rights framework.

The theme of this issue is a complex one. Epistemology, a Greek term meaning the study of knowledge, is a branch of philosophy. While I make no claims to mastering this discipline, as a former academic, producing new knowledge has been a major part of my professional work. This task continues in a different shape in my role as editor. Editors are considered to be gatekeepers of science; it is an editor’s foremost responsibility to assess the limits and possibilities of new knowledge and ensure that research and new findings meet the criteria of rigour and rationale to contribute to the pool of knowledge. The theme of this issue extends beyond knowledge production and engages with the domain of evidence-based policy and practice that appeals to the advocate in me. As Johann Wolfgang von Goethe has said, “Knowing is not enough, we must apply; willing is not enough, we must act.”

What is evidence?

Knowledge is considered to be a claim justified by solid, good-quality evidence. Some scholars define evidence as that which “concerns facts (actual or asserted) intended for use in support of a conclusion”, obtained through experience or observation (empiricism) or reasoning and rationale (rationalism).¹

The process of creation of knowledge and generation of evidence, often through research, is controlled by several checkpoints, each determining the type of research being funded, conducted and communicated to shape and inform the discourse, policies and practices (Figure 1).

Figure 1 Research-policy-practice continuum.

Governmental funds, which are the most common source of research support, can be subject to ideological and political influences, hampering conduct of certain areas of research and encouraging others.^2,3 Research funding, even from private donors, can also skew the research landscape, a phenomenon known as funding bias, attracting researchers to certain topics and diverting attention from other, often controversial, topics. The articles in this issue will illustrate some of these factors.

Political factors can have far-reaching consequences beyond national borders, and dictate not only what research is conducted and applied, but also what research is published. This is demonstrated by the refusal of publication from authors from sanctioned countries⁴ or prohibition of publication of research on various aspects of SRHR that stands against the political stance of governments or that reveals the reality of marginalised populations in those countries.

Regardless of availability of rigorous and relevant knowledge, policy decisions are not solely based on evidence, but are often motivated by a wide range of political and ideological preferences, including electoral promises, economic constraints and other competing interests.^1,3 Hence, the relationship between research and policy is a complicated one and there can be a chasm between the two. Across this continuum of research-policy-practice, while there are instances when scientific rigour goes hand in hand with values, power and interests, there are also many inevitable clashes.

What’s in this issue?

Sexual and reproductive health research has historically been a subject of significant political interest. In parallel to ideological attempts to restrict conduct of research in certain areas or publication of particular research findings, there have also been instances where fabricated information has been circulated to support a particular ideological or moral stance. A case in point is the myth that women routinely suffer from severe post-abortion depression, which has been refuted scientifically.⁵ Another untruthful claim is put out by the Catholic Church, which argues that “HIV is small enough to pass through a condom”, reflecting a moral and not a scientific position.⁶ In addition, there are numerous examples of research evidence being ignored when developing policies or, even when policies exist, in putting them into practice. This is clearly demonstrated by mounting evidence of the ineffectiveness of, and the harm caused by punitive laws not grounded in evidence, such as criminalisation of safe abortion, same-sex practices or sex work. Such ignorance and misinformation results in millions of preventable deaths and unnecessary ill-health, in particular among those living in poverty or at the margins of society.

In this issue, Reproductive Health Matters is proud to publish a diverse range of findings from research projects and perspectives that highlight the complexities, strengths and weaknesses of the process of knowledge creation and uncover the frequent disconnect between research, policies and practices, elaborating on its implications.

Filling gaps with experiential knowledge

The personal historical note by Jane Cottingham illustrates how the reproductive health research agenda of WHO and partners was transformed following inclusive dialogues between researchers and women health advocates. Her paper describes how information, perception and the practical realities of women helped fill a critical knowledge gap regarding feasibility, uptake and utilisation of fertility-regulating interventions.

Knowledge and evidence are contextual, and qualitative research is essential in providing insight into the cultural, social and economic contexts. Experiential knowledge of end-users and stakeholders, as well as professional data from programme managers, are important forms of evidence, essential for effectiveness in health service delivery and for ensuring optimal utilisation of interventions. For example, in her article, Rosalijn Both provides a glimpse of the sexual reality of the urban youth in Addis Ababa, Ethiopia, enabling an understanding of why emergency contraception is their preferred contraceptive method. This paper emphasises the need for experiential knowledge to stimulate more research and inform policies.

Gathering reliable stakeholder information and disseminating knowledge can take many forms, as demonstrated by Krishnan et al and Musoke et al. Visual communication has proven to be a powerful medium for collecting and transferring knowledge and conveying key messages, in particular to and from populations with limited literacy. Photovoice is an example of a community-rooted research methodology that uses images to allow researchers to capture information about the underlying reasons for ill-health and the challenges in the health structure of a community (Musoke). Using social media, Krishnan and Dalvie discuss the making of an animated film and how it conveys accurate messages about the consequences of unsafe abortions in Asia, promoting women’s agency and their rights to reproductive choices affecting their own bodies.

Professional knowledge of service delivery, gathered systematically, but learned through the daily challenges that programmers struggle with, provides another set of evidence important for improving feasibility and implementation of SRHR interventions. It has been proven time and again that interventions must not only be safe and efficacious in trial or experimental settings, but that they must also be effective and feasible in real life. In their paper, Keyonzo et al share their experience in scale up of family planning programmes (initiated by external donors) in Kenya through transfer of operational and service delivery knowledge, as well as power and leadership, to local authorities and stakeholders. Such an approach is highly warranted, in particular in an era when the sustainability of programmes initiated by foreign development aid is a key objective.

Programmatic evidence can not only improve acceptability, feasibility and sustainability of SRHR programmes, but can also provide a basis for policy changes. In their paper, Freedman et al showcase how programmatic evidence led to changes in legislation and policy in the United States, allowing nurse-practitioners, certified nurse-midwives and physician-assistants to provide early aspiration abortion following specialised training. Nevertheless, the paper highlights that evidence is not automatically translated into policy and practice, but must be accompanied by efforts by well-versed advocates to incorporate it into positive laws and improved programmes.

Clash of evidence, policy and practice

Despite knowing that the experience of lived realities and growing insights into the causes of ill-health can improve the effectiveness of health interventions and health outcomes of individuals and communities, research is not unbiased and is subject to external influence. Forbes’s paper reminds us how evidence can be skewed by political pressure and narrow-minded ideologies. In her commentary, she criticises the current and past ideological environment in the US for creating a conspicuous knowledge gap on HIV prevention and treatment for sex workers. Such conspicuous knowledge gaps, resulting from ideological and political preferences and legal constraints, are not limited to sex workers; this is demonstrated by Schwartz and Baral, who expose the unmet (and unknown) fertility needs and desires of other marginalised women, such as women living with HIV, lesbians and transgender people.

Even where evidence is strong and consistent, there can be political and ideological factors which result in failure to implement evidence-based programmes. Not surprisingly, abortion is the exemplary case of our failure to implement evidence- and rights-based laws and policies. Despite overwhelming evidence on the safety of manual vacuum aspiration and medical abortion, and the solid data demonstrating that criminalisation of abortion does not stop women from seeking to terminate unwanted pregnancies, universal access to safe abortion within comprehensive SRHR services is still a long way from being achieved⁷

It is not a secret that misinformation on abortion procedures is rampant across the globe. In their paper on the impact of misconception of legislations against sex-selective abortions in a district in India, Potdar et al show how misinformation about the law and fear of prosecution on grounds of sex selection is having a negative impact on women’s access to safe abortion, in particular in the second trimester, should the foetus happen to be female. Faulty enforcement of a law aimed at combating gender discrimination has been shown to further undermine women’s position and impact access to safe abortions, even in the first trimester. This is yet another example of how laws, intentionally or unintentionally, create barriers for women to access essential sexual and reproductive health services.

Other strategies to reduce women’s access to sexual and reproductive health interventions, including safe abortions and contraception, could be de-prioritising such interventions and distorting resource allocation. Governments have often used the excuse of scarce resources and competing health priorities to divert funds from certain sexual and reproductive health services and interventions not in their political interest. With negotiations and reforms on the global financial mechanism for development currently underway (the Third International Conference on Financing for Development is happening as this issue of the journal goes online), Hoen et al provide insight into the complexities of international development financing and the new tracking and financing structures, exposing the risks of a direction that can further undermine and reduce SRHR support, especially for underserved populations. Transparent budgeting and financial records are necessary to hold governments accountable for their commitment to meeting the ICPD agreements and the Sustainable Development Goals (SDGs) related to sexual and reproductive health. Commitment to meeting these SDGs requires political will, not only in global multinational negotiations, but also at national and local levels.

Yet despite these formidable barriers, the perseverance of communities in reaching out and supporting women and circumventing various obstacles has been remarkable. Drovetta presents Safe Abortion Information Hotlines in several countries in Latin America as a successful community-based effort to ensure the availability of accurate information about medical abortion where access to legal and safe abortions is restricted, aiming to minimise the risk to women who cannot access or afford legal safe abortions.

The issue also includes papers demonstrating the silos between evidence, policy and practice. Waldman et al showcase the success and diversity of SRHR mHealth (use of mobile devices to support practice of medicine and public health interventions) in South Africa, while highlighting the disconnect between policy and practice. The authors argue that investment in technology to support SRHR-related interventions continues to be overshadowed by political and religious ideologies, explaining why many mHealth interventions focus on non-controversial topics, such as maternal health, and shy away from contentious ones.

In addition to the gap between evidence and policy, there continues to be a lag before putting evidence into practice. Schantz et al report an alarmingly high rate of episiotomy in a referral hospital in Phnom Penh, Cambodia, revealing practices that have failed to progress with evidence-based normative guidelines. Rigorous evidence has shown the potential disadvantages of routine episiotomy⁸ and although WHO has advised against it, this practice continues to be used widely.⁹

I hope that you enjoy the collection of the articles in this issue and feel inspired to keep on reading and contributing to the journal as Reproductive Health Matters continues to encourage creation of new knowledge.

I would like to take this opportunity to also share some ongoing organisational changes and aspirations for the future.

RHM in transition in more ways than one

This 45th issue of Reproductive Health Matters marks the organisation’s move into a period of significant change and development. More than 23years since its first issue, RHM has given me the honour of leading the organisation into the future. Under Marge Berer’s leadership, RHM has experienced tremendous growth and built its reputation as a source of in-depth knowledge on sexual and reproductive health and rights. RHM is certainly not just a journal. It never has been. RHM not only publishes cutting-edge research and supports dissemination of evidence and global voices, as demonstrated by the theme of this issue, it is also eager to critically analyse the patterns of knowledge creation. Furthermore, RHM encourages publication of other forms of knowledge and insights that receive less attention in traditional scientific journals, but that can inform policies and programmes. Importantly, by bringing together science and human rights, it has become an influential voice of reason and an outspoken advocate for sexual and reproductive justice.

It has been a pleasure to co-edit this issue with Marge and benefit from her knowledge during this transition period. I would like to offer her my heartfelt appreciation for her vision of Reproductive Health Matters and for growing it to what it is today.

Improving the journal’s efficiency

The transition in RHM’s leadership coincides with some other important changes in the organisation. Following a decision some time ago, the transition to an online-only publication is being completed with the publication of this issue. This is a significant change, which has unfortunately resulted in considerable delays to the publication.

The shift to online publication will enable us to move with the times and use our resources more effectively (and be more eco-friendly), while maintaining a rigorous peer-review process to continue producing a publication of quality. Online-only publication doesn’t exclude the possibility of printing an issue if required for relevant events or important occasions, and individuals can order a print copy. However, it will eliminate the sizeable costs of printing and shipping thousands of journal issues which, given our capacity, has also limited our reach, and enable us to allocate the funds to wider dissemination of, and easier access to, journal articles.

Other key forthcoming plans to improve our efficiency include a review of the journal and its publication policies and procedures, aiming at a more rapid peer-review process and shorter turn-around time following article submissions. This will require some internal structural changes, including reviewing and expanding the editorial board and appointment of new associate editors in 2016. These changes, which will take some time to take effect, will allow us to explore the possibility of more frequent publication – a prerequisite if we want to stay at the forefront of and respond to the rapidly changing and expanding discourse on sexual and reproductive health and rights.

Expanding the reach

Until now, RHM has operated as a subscription journal, which has limited access to the most recently published articles to subscribers, although all articles are open access one year after publication. To broaden access, in particular in the global South, RHM has offered supported subscriptions to organisations and groups in countries where the price of a subscription has been prohibitive, effectively allowing free access to RHM articles to those who would otherwise not have been able to receive the journal.

As we are moving to online publication, we are now shifting our model to “open choice” publication. This new model offers authors the option to publish their article Open Access for a modest publication fee, allowing immediate free access to their full text article without any extra steps and log-in requirement. This new model is accompanied by a generous fee waiver policy: publication fees are waived for submitting authors in resource-limited countries¹ who opt for open access, making their articles free to both authors and readers. For authors in middle-income countries with limited resources or those without institutional support who wish to publish open access, a fee waiver strategy is being negotiated with our publisher to ensure that the open access fee never poses a barrier to publication. This is in line with our ongoing strategic allocation of funds towards supported subscriptions to ensure that the subscription fee is not a barrier to reading our journal. For the occasion of this transition, the articles published in this issue will be open access in the first six months.

I am also pleased to announce that RHM now has a new website, which offers a fresh look and a more engaging and interactive environment that simplifies user experience and encourages authors, readers and website visitors to interact with us more easily. The new website offers more visibility to our long-lasting partnerships with various institutions, in particular with the RHM editorial teams in Brazil, China, Egypt, India, Peru and Russia that translate RHM articles into various languages, contributing to widening the reach of RHM publications. Translated articles are easily accessible free of charge via the RHM website, and negotiation with our publisher is underway to ensure that they are also available through the journal platform on Elsevier’s website. We invite our readers and authors to visit the new website and share your feedback on these changes with us.

Retaining diversity

I would like to emphasise my commitment to preserving the diversity and the global nature of the journal. The commitment to diversity does not only apply to people involved in or contributing to RHM, but also the range of topics covered in our analysis. Although RHM will continue to encourage narratives that reflect the unique challenges to sexual and reproductive health and rights faced by women around the world, it is also committed to embracing the diversity that the gendered nature of SRHR brings to the table, including promoting the sexual and reproductive health needs of women, men and people with diverse gender identities and expressions and sexual orientations.

I hope the new online-only format and editorial policies will achieve important gains for the journal and its readership in the days to come. These changes will ensure that the journal remains relevant and accessible through a wide range of online platforms and remains current in the crowded arena of peer-reviewed publishing.

In line with our aspiration to play a more proactive role, new technological solutions will allow RHM to operate as a dynamic platform for exchange of information, knowledge and evidence and encourage timely responses to the emerging issues in the field. Utilising social media channels and optimal mobile technology will boost our engagement with the younger generation in order to attract new advocates and new energy that could strengthen the SRHR movement and reinforce advances towards universal sexual and reproductive health and rights. As ever, we are committed to continue providing editorial support to authors when needed to strengthen their voices, sharpen their arguments and polish their writing in order to maximise their contribution to the pool of growing evidence.

Upcoming theme

The next issue of RHM, which is planned for publication towards the end of the year, will be looking at a spectrum of issues relating to sexuality, sexual rights and sexual politics. It will examine the implications for communities of progressive, as well as conservative, laws regarding sexual health and sexual rights, cover a range of local and global issues, and share perspectives that include both the personal and the political.

I look forward to working with you and maintaining an open forum for dialogue and conversation with the aim of expanding and improving RHM and its contribution to the field of sexual and reproductive health and rights and hope that you will send me your questions, feedback and suggestions.

Acknowledgements

I would like to warmly thank Jane Cottingham, Marge Berer, Rodney Kort, Sahar Rad, Christina Zampas, Pathika Martin and Lisa Hallgarten for reviewing and providing feedback on this editorial.

Notes

1 Countries listed in Research4Life http://www.research4life.org/eligibility/.