By Jason Nagata, MD, MSc
Adolescent health has come into the spotlight of the global health and HIV agendas as a result of its emphasis in three major global strategies: the Sustainable Development Goals; the Global Strategy for Women’s, Children’s, and Adolescents’ Health; and Start Free, Stay Free, AIDS-Free. Adolescent health has also recently been featured in the global health context through the Lancet Commission on Adolescent Health and Wellbeing and the World Health Organization’s Accelerated Action for the Health of Adolescents (AA-HA!). Approximately one-sixth of the world’s population are adolescents, with 90% residing in low- and middle-income countries.
Learning Research Prioritization Methods
Given limited resources, there is a need to prioritize research and support decision-making for health investments, especially for research in low- and middle-income countries. Some methods for identifying research priorities include the Child Health and Nutrition Research Initiative (CHNRI) method, the Delphi method, and consultations. The CHNRI method was developed in 2005 and has since become the most widely used research priority setting methodology with more than 50 applications, mainly in global child health. In brief, this method involves defining the health issue, identifying experts to participate and submit priority research questions, and peer ranking of the questions to produce a prioritized research agenda.
Through an internship at the World Health Organization’s Department of Maternal, Newborn, Child, and Adolescent Health, I had the opportunity to learn about the CHNRI method and coordinate a research prioritization exercise on global adolescent health. This exercise encompassed eight different areas including communicable diseases, injuries and violence, mental health, non-communicable diseases, nutrition, physical activity, substance use, and health policy. I spent my internship identifying the top experts in these fields, designing the surveys for the experts to propose and rank priority research questions, and conducting the data analysis. After presenting the preliminary results at a Technical Consultation at WHO Headquarters in Geneva, Switzerland, we published the ranked research priorities in the Journal of Adolescent Health and a mixed-methods analysis (word cloud and content analysis) of cross-cutting themes in the June 2018 issue of the Journal of Global Health.
A Global Research Agenda for Adolescent HIV
Having learned the unique CHNRI study design and analysis methods through my WHO internship, I have been fortunate to be able to collaborate on other research prioritization exercises, including a CHNRI priority setting exercise for a global research agenda related to adolescent HIV, a collaboration between the WHO and the International AIDS Society. This comprehensive exercise generated 986 research questions on adolescent HIV from 323 experts based in 67 countries across all WHO regions, which were distilled into a prioritized research agenda. This led to the identification of priority themes in the three adolescent HIV topic areas: testing, treatment, and service delivery. The prioritized research agenda is published in the Journal of Acquired Immune Deficiency Syndromes this month and a commentary in the Journal of Adolescent Health.
Some of the top research priorities identified included:
- Research on interventions to improve retention in care as adolescents and young adults have been shown to have a higher loss to follow-up rate than other age groups
- Development of strategies and interventions to improve access, uptake of HIV testing, and linkage of newly diagnosed adolescents to HIV treatment
- Research on strategies to sustain high levels of adherence and how to most effectively monitor adherence among adolescents.
Application to the Field: Adolescent Shamba Maisha Study
The priority setting exercises helped me to determine which types of research I will pursue as I embark on my career in global adolescent health. For instance, since 2008, I have researched nutrition and food security among people with HIV in Western Kenya under the mentorship of Craig Cohen, MD, MPH and Sheri Weiser, MD. These initial medical school experiences allowed me to conduct observational research and secondary data analysis. Working on the adolescent priority setting exercise later during pediatrics residency helped me to understand the importance of interventions research in adolescent HIV prevention. As a result, I decided to pursue an interventions research project on this topic during my adolescent and young adult medicine fellowship at UCSF.
Rather than continuing to work on observational research, I chose to work with Drs. Weiser and Cohen on interventions research through the Shamba Maisha cluster randomized controlled trial, a household-level agricultural and finance intervention for families affected by HIV in Western Kenya. While the trial collected data on the adult heads of households and children under five years old, data was not previously collected on the adolescents living in the study households. With the support of a grant from the Mt. Zion Health Fund through the UCSF Resource Allocation Program, I will collect data on the adolescent girls living in the households. We hypothesize that the household-level intervention improves the nutritional, sexual and reproductive health of the adolescent girls within the households.
I am writing this blog entry from Kisumu, Kenya in the midst of training with the local research team prior to the launch of the adolescent Shamba Maisha study. Overall, participating in the WHO priority-setting exercise helped me to choose to work in adolescent HIV prevention interventions research as I embark on a career in global adolescent health.
Jason Nagata is a third-year physician fellow in the Division of Adolescent & Young Adult Medicine in the UCSF Department of Pediatrics.