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Sexual and Reproductive Health Needs, Experiences, Access to Services, and Interventions among The Rohingya and The Afghan Refugee Women of Reproductive Age in Asia: A Mixed Methods Systematic Review Protocol

Background: A humanitarian crisis disrupts the existing health care system limiting access to sexual reproductive health (SRH) services. The Asia and the Pacific region is home to 9.2 million refugees as of September 2020, most originating from Afghanistan and Myanmar. Afghan and Rohingya refugees have long been deprived of formal SRH education and face decades of discrimination in SRH services that can affect health outcomes. Purpose: This review examines the SRH status of Afghan and Rohingya refugee women of reproductive age in Asia and their needs and experiences in accessing these services and commodities. Methods: This protocol will follow the PRISMA checklist and standards for quality assessment of systematic reviews. The search strategy will be sought out all relevant peer-reviewed literature from five online bibliographic databases—SCOPUS, EMBASE (Ovid), MEDLINE (Ovid), CINAHL, and PROQUEST— using search terms related to the research questions. The review will include qualitative, quantitative, and mixed-method studies to understand the status of SRH of Rohingya and Afghan refugees across Asia. Content analysis will undertake following the Minimum Initial Service Package (MISP) objectives. The review will use the mixed methods appraisal tool (MMAT) to assess the quality of individual studies. However, no studies will be excluded based on this assessment. Result: The findings of this review will provide insight into the needs, status, and experiences of SRH of the Afghan and Rohingya refugee women of reproductive age in Asia and could contribute to health service planning to deliver evidence-based interventions and policies to improve SRH outcomes in humanitarian settings across Asia. Systematic review registration: The review was registered in the PROSPERO database with ID CRD42021253975.


BACKGROUND Introduction
Sexual and reproductive health (SRH) is fundamental to individual health and wellbeing and basic human rights and prerequisites of population and development (Desrosiers et al., 2020;Singh, 2018). The Sustainable Development Goals (SDG) targets include universal access to sexual and reproductive health and rights by 2030 (Munyuzangabo et al., 2020). However, war, conflict, genocide, violence, political instability, and natural disasters exacerbated by climate change have resulted in approximately one billion people requiring humanitarian assistance in 68 countries. This includes 54 million women, girls, and young people (UNFPA, 2020). At the end of 2020, 79.5 million people worldwide were forcibly displaced from their homes; among them are 26 million refugees, of which approximately half are less than 18 years old (UNHCR, 2020b). Refugees are people 'who have been displaced from their home due to war, conflict, violence, or persecution and have crossed an international border to find safety in another country'. Most refugees have been denied their fundamental human rights and are vulnerable to poverty and poor health.
Women and girls are disproportionately affected by war, conflict, and fragile situations, including epidemics such as COVID-19 UNFPA, 2020). Forced displacement increases women and girls' vulnerability to adverse sexual and reproductive health outcomes (Desrosiers et al., 2020;Hasan-Ul-Bari & Ahmed, 2018). One out of every three displaced women and girls face sexual, physical and gender-based violence in her lifetime; one in five girls are married before 18 years old and have inadequate access to sexual and reproductive health services. Around 60 percent of preventable maternal deaths occur in war-affected countries, and approximately 500 women die each day due to pregnancy and childbirth-related complications in humanitarian settings (Erken, 2017;UNFPA, 2018a). It is reported that around 3.2 million women undergo unsafe abortions, and 12 million adolescent girls give birth in humanitarian settings each year, with 15 percent experiencing obstetric complications (Singh, 2018;Zeid et al., 2015). A humanitarian crisis also adversely affects perinatal outcomes, including increasing the risk of congenital disabilities, early pregnancy loss, pre-term birth, low birth weight, and increases the prevalence of HIV and STIs (Chi et al., 2018;Zeid et al., 2015).
A humanitarian crisis disrupts the existing health care system limiting access to SRH services (Ivanova et al., 2018;Who, 2019). The Minimum Initial Service Package (MISP) developed by the Inter-Agency Working Group (IAWG) on reproductive rights in collaboration with UN, NGOs and donors aims to provide life-saving SRH services in humanitarian settings (Casey, 2015;Singh et al., 2018;WHO, 2010). MISP interventions include the identification of stakeholders for implementation, the prevention and management of sexual and gender-based violence, the reduction of HIV and STI related mortality and morbidity, prevention of newborn and maternal mortality and morbidity, prevention of unintended pregnancies and the delivery of comprehensive SRH services into primary health care as soon as possible. However, the latest IAWG's (2012-2014) evaluation found variation in the quality and effectiveness of the SRH services in humanitarian settings across different regions (Chynoweth, 2015).
The Asia and the Pacific region is home to 9.2 million refugees as of September 2020, with most originating from Afghanistan and Myanmar (UNHCR, 2020b). The prolonged and complex humanitarian crisis in Afghanistan because of armed conflict and political instability due to civil war and the Taliban insurgency has led to poor maternal health outcomes. These outcomes include a high maternal mortality rate at 638 deaths for every 100,000 live birth and newborn mortality of 40 neonatal deaths per 1000 live births (Masjoudi et al., 2020). Around 9.4 million Afghan refugees require humanitarian assistance, and 2.3 million women and girls of reproductive age need sexual and reproductive health services (UNHCR, 1951). Ninety-six percent of Afghan refugees have lived in Iran and Pakistan for over three decades. Pakistan provides shelter to the largest refugee population in Asia and the second-highest in the world, including 1.4 million Afghan refugee people, of which 46 percent are female (UNHCR, 2019).
The Rohingya are one of the world's largest refugee groups. They fled from Myanmar (UNHCR, 2020b), mostly to Bangladesh and Malaysia, to escape statesponsored genocide and violence. Bangladesh is home to around 1.2 million Rohingya, 52 percent of them are women, girls, and children. It is projected that, in 2021, 2 million people will require humanitarian assistance related to SRH in Bangladesh (IMO, 2018;UNFPA, 2020). In addition, Malaysia hosts over 102,020 Rohingyas, 55,000 Rohingyas live in Pakistan. India provides shelter to about 40,276 refugees, the majority of which are Rohingya, and Nepal accommodates over 19,574 refugees, including 600 Rohingyas (Saifi, 2017; UNHCR, 2019).
Around 316,000 Rohingya women of reproductive age (15-49) live in Bangladesh mostly in Cox's Bazar, including 63,700 pregnant women (UNFPA, 2018b). These women face challenges accessing sexual and reproductive health services, including skilled birth attendants and experience early marriage, forced marriage, early childbearing, and GBV (Huang & Schnabel, 2018). This further increases their risk of unintended pregnancy and unsafe abortion (Persson et al., 2021). The majority of Rohingya refugee women have experienced trauma, torture and rape (UN, 2011). Approximately 17 percent of Rohingya refugee women have experienced sexual assault (Riley et al., 2017). Rohingya women and girls are also vulnerable to trafficking and sexual exploitation (Goodman & Mahmood., 2019).
Several systematic reviews have examined SRH in humanitarian settings, including an investigation of the barriers to accessing SRH care (Tirado et al., 2020), the effectiveness of SRH interventions (Warren et al., 2015)and the utilisation, evaluation and quality of SRH programs in crisis settings Broaddus-Shea et al., 2019;Casey, 2015;Munyuzangabo et al., 2020;Singh et al., 2018). A recent systematic review by Desrosiers et al. (2020) identified the components of SRH interventions that are useful for young people in humanitarian settings in lower and middle-income countries. Few systematic reviews examine the health and wellbeing of Rohingya and Afghan refugees, and none focus on SRH (UNHCR, 2020c, 2020a). Studies in this area have focused on mental health and psychosocial wellbeing (Alemi et al., 2014;Tay et al., 2019), the integration of the human rights approach into public health and the health status and challenges of Rohingya and Afghan refugees (Divkolaye & Burkle, 2017;Joarder et al., 2020;Roozbeh et al., 2018). The only systematic review available assessing the needs and experiences of SRH in Africa was conducted by Ivanova et al (UNHCR, 2020b). However, this review is restricted to adolescents and young women in Africa with limited focus on interventions (UNICEF, 2020). Further research is needed to understand the SRH services available to Afghan and Rohingya women and girls across the Asian region and the experiences of these refugees accessing these services.

OBJECTIVE
The review will be guided by the following question: What are the sexual and reproductive health status of Afghan and Rohingya refugee women of reproductive age in Asia and their needs and experiences accessing these services and commodities?

Study design
This review will use checklists, the PRISMA flowchart (figure 1), and standard for quality assessment for systematic reviews (Moher et al., 2015). The review was registered in the PROSPERO database with ID CRD42021253975.

Search strategy
The search strategy will be sought out all relevant peer-reviewed literature using search terms relating to the research question. The following full search term will be used in the online database: We will search five online bibliographic databases: SCOPUS, EMBASE (Ovid), MEDLINE (Ovid), CINAHL and PROQUEST. To ensure the findings were contemporary, we will only include the studies that were published from 2000 to the present. This date is closely aligned with publication of the first field manual that provides a description of the Minimum Initial Service Package (MISP) in 1999 that aims to provide life-saving SRH services in humanitarian settings (Casey, 2015;Singh, 2018;WHO, 2010).

Condition or domain being studied
The review will adopt the standardised definition of sexual and reproductive health from the International Conference on Population and Development in 1994 and the WHO Reproductive Health Strategy (World Health Organization, 2015). The review will examine the SRH services defined in the Minimum Initial Service Package (MISP) in the humanitarian setting (Desrosiers et al., 2020;WHO, 2014). The MISP intervention includes family planning such as 'the provision of contraception education and advice, distribution of contraceptives to prevent pregnancy, to provide pre-conception screening and to space births, and education, advice, and counselling to achieve a healthy pregnancy outcome (WHO, 1999(WHO, , 2020a. Maternal and child health and neonatal care such as 'providing basic antenatal, neonatal, and postnatal care; newborn care, breastfeeding counselling; the management and referral of sick newborns (within the first 28 days of life); and community mobilisation strategies to promote birth and newborn care preparedness (Who, 2020;WHO, 2020b). Gender-based violence (GBV) including 'advocacy, counselling or GBV awareness including community education regarding GBV (WHO, 2010(WHO, , 2016 Sexually transmitted infection (STI) 'prevention and management; counselling and education in preventing STIs; and education aimed at preventing HIV and its consequences'. SRH issues also include 'menopause counselling in the management of menopausal symptoms; the management of fistula, and adverse effects of female genital mutilation (FGM)'. Inclusion and exclusion criteria are described in the table 1.

Participants/population
The review will focus on the SRH needs and experiences of Afghan and Rohingya refugee women of reproductive age (15-49) in Asia. (UNFPA, 2020). Specific populations of interest will be adolescent females, young women, pregnant young women, women and girls living with HIV, and sexual and gender-based violence victims. The review will focus on 35 countries from three sub-regions of Asia: West Asia includes the highlands of Anatolia, the Caucasus, and the Armenian and Iranian highlands (Britannica, 2021a), Southeast Asia located in the east of the Indian subcontinent and south of China (Britannica, 2021c), and South Asia consisting of the Indo-Gangetic Plain and peninsular India (Ryabchikov, 2021) as most of the Rohingya and the Afghan refugees are taking shelter in the mentioned regions (Wali et al., 2018).

Data extraction (selection and coding)
All data will be extracted from the findings section of full-text journal articles, reports, and other literature, which meet the inclusion criteria. The reviewer will independently read all included studies and will extract the following information in Microsoft excel form from the included articles such as the name of author/s, study setting, research objectives, study population, study design, and research findings. Extracted data will be coded manually to identify patterns by grouping codes into categories and then into themes.

Risk of bias (quality) assessment
The review will use MMAT (Mixed Methods Appraisal Tool) tools for assessing the quality of the individual studies (Hong et al., 2018). This tool-especially design for mixed-method review to assess the study's suitability, study design, study selection, methodology, data collection, data analysis, data presentation, discussions, and results (Dawson et al., 2015;Ivanova et al., 2018;NHS, 2013). However, papers will not be excluded based on this measure. This tool will assist in highlighted methodological issues and study types and clarify any impact that this may have on the quality of the data (Leung & Lin, 2019;NHS, 2013). The reviewer will do the quality assessment for each of the included studies (Divkolaye & Burkle, 2017).

Strategy for data synthesis
A content analysis will be undertaken of the extracted qualitative and quantitative data. The reason for using content analysis is to present data descriptively under different themes and classifications. The extracted data will be first grouped for synthesis, using the objectives outlined in the Minimum Initial Service Package for Sexual and Reproductive Health in Crisis Situations (WHO, 2017). Within each objective or set of activities in the MISP, data will be synthesised according to the needs and experiences, knowledge and perceptions of women and girls across each refugee count in various countries and a picture built to understand the different perspectives and contexts. Tables and concepts map will be used to explore the patterns and relationships between and within extracted data across the different categories. Finally, the main themes will be extracted by merging different groups and subgroups and will assess through discussion and critical reflection (Dawson et al., 2015).

DISCUSSION
Improving the SRH outcomes of Afghan and the Rohingya refugee groups across the Asian region to achieve the global public health targets in the SDGs is challenging. Although these refugees have different ethnic backgrounds and status in their former home countries (Afghans are a majority, Rohingya's are a minority), they share a common religious background and a fatalistic outlook on life (Rajaram & Rashidi, 1999;Shirazi et al., 2013). Afghan and Rohingya refugees have long been deprived of formal SRH education and face decades of discrimination in SRH services that can affect health outcomes (Ahmed et al., 2020;Higgins-Steele et al., 2018). There are considerable literature on the SRH of Rohingya and Afghan refugee women of reproductive age in Asia but remain un-synthesised. This review aims to consolidate the existing evidence on Afghan and Rohingya refugee SRH knowledge, experiences, access to services and interventions across low and middle-income countries in the Asian region to address this evidence gap. The finding of this review could contribute to health service planning to deliver evidence-based interventions and policy to improve SRH outcomes. This review findings will be presented at local, national and international forums and conferences and published in national and international peer-reviewed journals. Findings and insights will be disseminated to health services and community organisations active within the sector. Evidence-based understandings of the needs, status and experience of SRH of these refugee groups are highly relevant and translatable internationally, particularly to developed countries across Asia.