Using a Rapid Knowledge Translation Approach for Better Sexual and Reproductive Health and Rights in Bangladesh, Burundi, Indonesia, and Jordan

There is a growing need for approaches to support rapid knowledge translation processes that can create changes in policy and practice and that can apply to different country contexts. The collaborative rapid improvement model for knowledge translation in sexual and reproductive health and rights (SRHR) implemented in 4 countries improved SRHR practice and policies.


Supplement 1. Share-Net International Rapid Improvement Model as a phased approach Preparation Phase
The preparation phase includes writing the CRIM-KT concept note, establishing the faculty for the local knowledge platform team, assigning the collaborative project manager, appointing the collaborative chair, and recruiting the knowledge experts according to the following steps: • Establish the collaborative team (chair, project manager and knowledge experts) o Appoint the project manager. Role and responsibilities for the project manager include: ▪ Write vacancy for content & knowledge experts ▪ Organize brainstorm with country hubs on topic selection ▪ Organize expert meeting with staff & content experts ▪ Set up communication & support system with input from team ▪ Organize and plan learning sessions 1-4 ▪ Write evaluation report o Appoint the chair. The role and responsibilities of the chair include: ▪ Lead the knowledge experts team ▪ Provide technical expertise and advise on the methodology of CRIM-KT ▪ Take part in writing and reviewing the scientific article on the outcomes of CRIM-KT ▪ Review literature and develop the technical material for the learning sessions o Appoint knowledge experts. Role and responsibilities of the knowledge experts include: ▪ Teach and educate the collaborative teams of the country platforms during the learning sessions about specific technical topics such as: • Approaches to knowledge sharing and translation • Innovative knowledge translation tools • Presentation of state-of-the-art knowledge for selected SRHR topics • Best practices in knowledge use ▪ Develop of an outcome measurement system ▪ Assist country knowledge platform teams in designing the change package for each implementation period ▪ Work as a mentor for the teams during the implementation period ▪ Document the best impact (results) of implanting different change packages and share with the country knowledge platform teams during the third learning session. ▪ Brainstorm with country knowledge platform teams on topic selection ▪ Set up communication and M&E reporting system Supplement to: Meijers K, van der Kwaak A, Aqel I, et al. Using a rapid knowledge translation approach for better sexual and reproductive health and rights in Bangladesh, Burundi, Indonesia, and Jordan. Glob Health Sci Pract. 2022;10(2): e2100461. https://doi.org/10.9745/GHSP-D-21-00461 Implementation Phase: The implementation phase included conducting three international learning sessions and applying the gained knowledge through three action periods as follows:

Learning Session 1: Share-Net International Rapid Improvement Model & Capitalisation Workshop
• Country knowledge platforms prepare and present story board with ideas, opportunities and challenges • The Share-Net International Rapid Improvement Model for knowledge translation and use is explained by the collaborative chair. • PDSA Cycle is explained • Topic brainstorm session is organised to narrow the focus and scope • Specific focus and scope within the overall topic is decided • Senior leader for each country platform is appointed • Capitalisation workshop is organised • First change package is developed • Each country knowledge platform makes a planning for the first implementation period

Action Periods
During each learning cycle the country platforms test agreed strategies from the change package together with their local stakeholders. Key changes are implemented in a cyclical fashion. This process continues serially over time and refinement is added with each cycle; these are known as PDSA cycles of learning.
• Country platforms facilitate local learning sessions for their stakeholders • Change package is developed during the international learning sessions and is reviewed, updated and further developed by the local stakeholders during the local learning sessions • Share-Net International supports the local country teams in their improvement work • Collaboration and shared learning between the country platforms takes place • Knowledge experts assess collaboration and progress • Country platforms use each other as resources • Conference calls are held with the knowledge platform teams to update each other on progress, challenges, opportunities and lessons learned

Learning session 2 & 3: Country platforms learned and exchanged best practices in knowledge translation
• Problems and challenges are presented by the country platforms which are identified during the implementation periods that need to be addressed before the next action period, including problems with faculty and technical content • Country platform story boards are presented explaining the strategies used and what worked and what didn't work in the previous implementation period • Brainstorm session are organised on the next steps • Expert workshop 'Best practices in knowledge translation on child marriage and teenage pregnancy' is facilitated by the knowledge experts

Case Study Bangladesh
The knowledge platform 17 in Bangladesh is hosted by an organization that works on social and behavioral change communication and advocacy on SRHR issues. 18 The platform together with its members identified the lack of collaboration and the absence of knowledge on the consequences of child marriage (both physical and mental) at the field level due to lack of concentrated effort between the government, NGOs and CSOs as the main topic. These knowledge gaps as well as communication gaps resulted in limited knowledge sharing and translation into effective interventions to address CM.
In December 2017, the Ministry of Women and Children Affairs passed the controversial Marriage Restraint Act which stated 'if a marriage is solemnized in such manner and under such special circumstances as may be prescribed by rules in the best interests of the minor, at the directions of the court and with consent of the parents or the guardian of the minor, as the case may be, it shall not be deemed to be an offence under this Act'. This act has been subject to criticism from rights activists throughout the country and abroad, as it creates a loophole for parents to marry off their children legally. Besides, there is a growing number of interventions both by the Government and NGOs are addressing the issue of CM in Bangladesh. However, the country remains among the top ten countries in the world for CM. Therefore, the knowledge platform together with its members focused on addressing lack of collaboration and absence of knowledge throughout the learning sessions and action periods.
During the first action period, an information hub on the knowledge platform webpage to highlight projects that focus on CM, was created by the knowledge platform secretariat with support from the members of the CoP on CM. This was achieved through mapping the projects and disseminating an overview of research and interventions on CM in Bangladesh from 2010-2018.
During the second learning session, ten experts on CM were interviewed by team members of the knowledge platform and the results were published on the webpage to support the translation of tacit knowledge into explicit knowledge. Additionally, in collaboration with the members of the knowledge platform, a booklet titled 'Highlights of Initiatives Addressing Child Marriage in Bangladesh' (see figure 4) was developed by the knowledge platform to show the best practices for prevention of CM among actors in Bangladesh. 28 This activity highlighted the field experience from experts by translating tact knowledge to explicit knowledge.
The knowledge platform secretariat distributed the booklet among members of the platform and practitioners working on CM to help them learn about the work that other organizations do to prevent CM. During a knowledge fair, organized as an annual activity by the knowledge platform, the booklet and the knowledge collaboration between actors was presented and shared.
In the third action period, the knowledge platform together with the Child Marriage CoP members and the Royal Netherlands Embassy in Dhaka, organized a round-table discussion (see figure 5) to share the lessons learned in promoting the collaboration and agree on coordination among stakeholders, including the government of Bangladesh. Current strategies that effectively address CM in Bangladesh, lessons learned, challenges and follow-up action were discussed. During this meeting, the CRIM-KT methodology has shown to facilitate the identification of knowledge gaps and the translation from tacit knowledge of experts to explicit knowledge. The local stakeholders were impressed by the methodology and expressed their interest in participating again in such collaboration in addressing different SRHR issues. Practice changed after CRIM-KT was implemented. The collaboration between the CoP on CM, and government officials has intensified and facilitates evidence-informed working. enabled stakeholders to discuss which change ideas are feasible in terms of budget and time constraints, while providing space for experiencing new ways of working. Barriers were the varying degree of willingness of stakeholders to work together and the limited existing collaboration between NGOs and the government. Additionally, high staff turnover within participating organizations resulted in new stakeholders taking part in each learning session that needed to be updated.

Case Study Burundi
The Burundian knowledge platform 18 was hosted by an international non-governmental organization. The platform identified teenage pregnancies as their focus. The incidence of school-aged pregnancies in Burundi is alarming.
Only little evidence was available on the topic of TP. Therefore knowledge generation was identified by the representatives from the knowledge platform, the National Reproductive Health Program of Burundi (PNSR) and the National Institute of Public Health as a key priority during the first learning session. Participants developed a change package which included a desk review as well as a stakeholder mapping and analysis. The mapping of stakeholders (see figure 6) working on teenage pregnancy was conducted by the representatives of the knowledge platform with technical support from Share-Net International (SNI). Furthermore, the knowledge platform initiated and coordinated a desk review of teenage pregnancy interventions in international literature performed by an intern at SNI. The desk review elaborated on known best interventions to reduce or prevent adolescent pregnancy in Burundi, Kenya, Ethiopia & the Demographic Republic of Congo. A reflection paper was written by the same intern on how the Joint Program Intervention Should or Might Improve Adolescent Pregnancy in Burundi. The Joint Program is a five-year partnership with the aim to improve SRHR of adolescents and young people in Burundi.
During the second action period, a joint broadcasting initiative in the form of a talk show on 12 radio stations was organized by the knowledge platform with support from the host organization to make the general public more aware of risk of teenage pregnancies. The knowledge platform coordinator and the National Reproductive Health Program director participated in the panel to respond to direct questions from the audience. This activity was financially supported by an external funder.
In the third action period, a round table (see figure 7) was organized by the knowledge platform representatives to reflect on improving mechanisms for monitoring teenage pregnancies in Burundi. During the round table, participants proposed to the National Reproductive Health Program representatives to conduct a thorough analysis of existing monitoring mechanisms of adolescent pregnancies in Burundi in order to identify concrete knowledge gaps and propose correcting measures. The report 'Analyzing the current mechanisms of monitoring adolescent pregnancies in Burundi' was drafted in French by a team encompassing representatives from the National Reproductive Health Program, the National Health Information Management System and the knowledge platform secretariat. 29 The report included recommendations on how the existing health information system of the government can improve the documentation of TP at the national level.
CRIM-KT in Burundi has proven to be a useful strategy to foster collaboration between stakeholders within a short timeframe with clear outputs in the form of different knowledge products. The participants mentioned, as a barrier for change, that focusing on knowledge translation strategies while there is no current data and existing literature available on TP in Burundi, made it challenging to improve policy and practice. The other barrier mentioned was the limited financial budget to organize and execute activities. Organizing the local learning sessions and action periods was relatively expensive compared to the other hubs, because of stipends paid to participants, price of venue rental, and facilitator fees.
In Burundi the local learning sessions and action periods could only be organized by the knowledge platform after receiving prior permission from the Burundian government. Furthermore, due to governmental regulations, the learning sessions had to be partly facilitated by the Program Manager of National Reproductive Health Program (PNSR) even though this person was not present during the international learning sessions during which the representatives of Share-Net Burundi were trained on the methodology.
The second learning session was organized later than originally planned because the Burundian government suspended all workshops in May 2018 to prioritize the local elections. End of September 2018, the Burundian National Security Council decided to ban international NGOs for the consecutive three months. This ban also suspended operations of the host of Share-Net Burundi. This meant a delay in organizing both the second and the third learning session.

Case Study Jordan
The knowledge platform in Jordan is hosted by the Higher Population Council (HPC), a semi-governmental organization with the authority to direct national efforts on sustainable development, population issues, and reproductive health. The knowledge platform selected child marriage as their topic because sufficient evidence on the harmful consequences CM already existed and more collective efforts were needed to make sure that different actors, including the government, took collaborative action to implement policies and programs to address CM.
During the first local learning session, stakeholders decided to develop a national action plan to end CM. 26 The plan aimed to provide a general framework for limiting the marriage of individuals under the age of 18 and a manual of short and medium-term national interventions for the following five years. The action plan was formulated based on the results of a comprehensive study and a policy brief on CM in Jordan. 30 The planning process consisted of several stages that took place across the different learning sessions and action periods, including four round table discussions with different actors. The action plan took into account the financial capabilities and human resources of the national implementing partners and its related programs. The final action plan was successfully presented by the Secretary General of the HPC to the Prime Minister, and endorsed by the cabinet. Furthermore, as a result of this whole CRIM-KT process, the legal age for marriage increased from 15 to 16 years. The platform held several meetings with potential donors to share the action plan for reducing CM in the country and the executive program for the years 2018-2022 to explore funding opportunities for the different activities included in the plan. With external funds, a workshop on the mechanisms for integrating CM in the plans of civil society institutions and societies was held.
During the second and third local learning session, a national multi-stakeholder partnership was established by the King Hussein Foundation. During the following action periods, the partnership raised their own funds and implemented joint activities. In total seven stakeholders participated in conducting a research to understand the economic and social drivers that influence CM in Jordan. An awareness training on CM was conducted by two stakeholders at hospitals for 100 participants. A multi-stakeholder project targeting Syrian refugee girls at schools (aged between 14 and 16) and their families using health and socioeconomic approach to reduce CM was developed and externally funded. Two partners conducted an awareness campaign at 60 schools around CM.
Knowledge experts and participants deemed as reasons for the successful change in Jordan, the involvement and leadership of HPC as a semi-governmental organization which led to more participation from the public sector and NGOs. Additionally, multi-stakeholder approaches set-up during the local learning sessions to address CM were successful. The host organization produced a detailed study and a policy brief on CM together with the Jordanian knowledge platform prior to the start of the CRIM-KT approach. in the recommendations from the policy brief supported evidence-based decision making and led to the approval of the study and the national action plan by the Prime Minister and cabinet.
Barriers identified by the participants to implement the approach were that not all stakeholders had the same willingness to put efforts in addressing CM. Most prominently is the limited available funding from governmental and non-governmental entities to implement the national action plan. Lastly, there was a lack participation of the private sector.

Case Study Indonesia
An international non-governmental organization, which was part of a large five year program on reducing child marriage, teenage pregnancy and female genital mutilation (FGM) in Indonesia 20 implemented the rapid improvement model. As theme, they identified the harmful interpretation of the merarik culture (elopement) that supports 'kidnapping' of young girls which influences the occurrence of CM and a high divorce rate. 31 In preventing CM in West Lombok, each stakeholder tends to work independently (government institutions and local CSOs), and not involving religious and traditional leaders. Through the CRIM-KT approach in West Lombok, the leading INGO together with another member of the alliance gathered all stakeholders/gatekeepers. Increased collaboration of these various stakeholders was facilitated through several learning sessions. During the first learning session participants mentioned as reasons to select this topic, the available evidence on harmful consequences of CM, the alignment with local government priority and the strong linkage with interests of the existing multi-stakeholder district working group. The misinterpretation of the merarik culture was identified by the stakeholders as a root cause. The first change package focused on increasing understanding around the merarik culture and engaging stakeholders and conducting a needs assessment among stakeholders. Furthermore, the existing district working group was strengthened by acquiring co-funding from government to organize meetings and by planning and organizing more structural and systematic meetings with agenda setting focusing on improving policy and practice in relation to CM in West-Lombok. This resulted in a Memorandum of Understanding (MoU) among stakeholders to address CM because of elopement. Customary laws that have only been conveyed by mouth to mouth tend to experience a shift in meaning. In order to return the customary merarik law to its original meaning, a written document was needed. That is why, during the second action period, the involved stakeholders agreed the change package would focus on the development and launching of a technical guideline to clarify and bring back the authentic concept and process of merarik. 27 Subsequently, village heads in Lombok received training from religious leaders on the guideline to be able to refuse to give permission for CM. The traditional leaders facilitating the trainings were supported by the District Office of Population Control, Family Planning, Women's Empowerment and Child Protection and the INGO. The training of village heads on the guideline was integrated by the leading INGO in the 5-year program to address CM, teenage pregnancy and FGM. During the third action period a multistakeholder partnership was set-up to develop a syllabus for training on merarik guideline and engaging stakeholders to adopt the guidelines through advocacy efforts. The implementation of the guideline was monitored and documented by the INGO that implemented the rapid improvement model. In 2019, the local guideline on the merarik cultural practice was integrated in the existing Local Regulation of Child Marriage Prevention issued by the parliament in West Lombok which can be considered a long term sustainable change. Furthermore, throughout the process three off-and online newspaper articles regarding the merarik guideline were published. The Department of Women Empowerment and Family Planning of West Lombok allocated budget to expand the coverage of the training in the villages outside the 5-year program.
Participants from Indonesia and knowledge experts gave several reasons for successful change in Indonesia. These include the alignment with stakeholder priorities, support from local leaders, availability of the already existing multi-stakeholder district working group, the embedding in a large 5-year program with strong partners, input from stakeholders about the feasibility of the project, and the implementation of the model at local instead of national level as the scale is smaller and more feasible. Participants valued the approach for its encouragement to prioritize activities, think about next steps and consider the feasibility of achieving change in each action period. Also, the intensity of the approach, in terms of number of action periods in short time, and the specific focus were said to be important factors. Elements that hampered implementation of the rapid improvement model were language barriers