Introduction

Research capacity strengthening (RCS) programs in low- and middle-income countries (LMICs) are needed to foster the discovery of context-specific solutions to improve patient outcomes and population health. In the context of sexual and reproductive health (SRH), the World Health Organization (WHO) Human Reproduction Program defines RCS as a process of individual and institutional development that leads to higher skill level and greater ability to perform valuable research that is linked to improved operations of SRH programs [1, 2]. RCS would necessitate understanding the current strengths and goals of the collaboration. In practice, RCS approaches are broad and include supporting partnerships, improving the capacity of individual researchers through training courses, and developing leadership skills [3].

A comprehensive approach is needed to strengthen independent researcher capacity sustainably and improve SRH in LMICs. Researchers need the skills to build on local evidenced-based research outcomes to effectively reduce maternal mortality while improving SRH research. Over the past several decades, numerous RCS reviews have been conducted, and various frameworks have been proposed outlining approaches for capacity strengthening in LMICs [4–14]; however, none, to our knowledge, focused explicitly on SRH. There remains a limited understanding of reproductive health research strengthening programs and their outcomes. More information is also needed to understand how SRH research is sustained after program completion. Strengthening our understanding in this realm will help to inform health policy in LMICs.

Researchers and institutions with strong research programs can ultimately influence health system strategy, drive policy changes, and shift power between LMICs and high-income countries (HICs) [15–17]. Because a large share of health research funding in LMICs comes from HICs, financial control and decision-making power are often constrained in these settings [18]. As a result, health interventions are often dictated by those outside the country where they take place. This power disparity is further reflected in research publications from these settings [19]. Resident researchers most familiar with the local context and values are often excluded from the research [20]. Even when participating in research, they are often not given appropriate credit [21]. The sponsor, researchers, and pertinent stakeholders, including community boards and host-country authorities, should engage in dialogue and negotiation to establish and attain precise capacity-strengthening goals [22]. These parties should collaborate to enhance research capacity within the country’s health system, ensuring its sustainability for continued knowledge generation [22]. It’s crucial for local principal investigators to be actively engaged in the research endeavor [22]. Greater research capacity will result in more research carried out by local researchers, resulting in local knowledge production created within the priorities and values of residents [19, 23].

We conducted a scoping review of the literature to identify and synthesize strategies used in SRH research strengthening programs in LMICs. The scoping review explores the existing literature and aims to describe the format, duration, topics covered, and outcomes of program interventions to strengthen SRH research in LMICs. The review also explores how SRH research capacity is sustained after program completion in LMICs and identifies gaps in the literature about how SRH research programs influence patient outcomes and health policy. The overarching goal is to use the literature to inform efforts to successfully implement current and future programs to strengthen SRH research programs while fostering long-term sustainability and acknowledging the power imbalances that hold progress back in LMICs.

Materials and methods

The scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Review (PRISMA-SCr) guidelines [24]. A comprehensive search of the literature published between January 2011 and August 2023 was conducted by a health sciences informationist (GKR). Discrete searches were conducted in nine databases: MEDLINE via Ovid, Embase via Elsevier, Scopus, CINAHL via Ebsco, Web of Science, PsycINFO via Ebsco, Women’s Studies International via Ebsco, CABI Global Health and Global Index Medicus. No restrictions on language were applied. The original literature search was implemented in November 2021. A search update was conducted in August 2023. The timeframe of 2011–2023 was chosen to capture the most recent and relevant literature in the field. This period ensured coverage of current research trends, methodologies, and findings while managing the scope of the review. Focusing on the last decade also aligns with the need to explore contemporary issues and developments in SRH research strengthening programs in LMICs.

Search strategies were constructed by combining search terms representing three search concepts: (1) sexual and reproductive health, (2) research strengthening or capacity building, and (3) low- and middle-income countries (LMIC) or low-resourced regions. The third concept was represented by variations on the Cochrane Effective Practice and Organisation of Care (EPOC) LMIC search filter (v.4) [25] in all databases except for Embase, CABI Global Health, and Global Index Medicus. The University of North Carolina’s Developing Country / Low-Middle Income Searches filter (2019 update) [26] was used in Embase. No LMIC search filters were used in CABI Global Health or Global Index Medicus. The World Bank list of country income status was used as a criterion to identify a country as an LMIC [27].

After removing duplicate articles in EndNote using the Bramer method [28] and removal of identified retracted articles in Zotero, a total of 2315 articles were exported to Rayyan (https://www.rayyan.ai/) for title and abstract screening. Additional literature was also identified through hand searching of cited references of articles selected for full-text screening.

Study selection

Inclusion and exclusion criteria.

Regarding inclusion criteria, articles needed to describe an SRH RCS program, be conducted in an LMIC, and be published from 2011–2023 in peer-reviewed journals. The WHO definition of health research was used, encompassing the following areas of activity: measuring the health problem; understanding its cause(s); elaborating solutions; translating the solutions or evidence into policy, practice and products; and evaluating the effectiveness of solutions [29]. The included articles needed to describe programs aimed at allied and public health professionals. Qualitative, quantitative, case study, and mixed methods studies were included. Table 1 shows the inclusion and exclusion criteria for the review. Reporting a program evaluation was not part of the inclusion criteria.

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Table 1. Inclusion and exclusion criteria for this scoping review paper including literature published 2011–2023.

https://doi.org/10.1371/journal.pgph.0003789.t001

Screening process.

At least two authors (JB, EA, RG, FJD, TE, YS) reviewed and coded each article. The team reconciled disagreements through screening and discussion with at least one additional coder. If a coder was uncertain whether an abstract met inclusion criteria, the article was put forth for full-text screening. During the full-text screening, the same procedures for review were followed as in the title and abstract screening. Articles found through hand-searching reference lists of all identified articles for full-text screening were also screened for inclusion. S1 Appendix provides a data extraction form with bibliographic information for all full-text articles (n = 57) screened for inclusion.

Data extraction.

Relevant information for included articles was directly extracted using a structured form that included information on the lead author, title, and year of publication (S1 Appendix). The goal of the SRH research capacity strengthening program along with the country where it was located were included as was a summary of the sample size, population, and study design. We report the SRH research intervention frequency and format along with learning activities. Text describing reported intervention outcomes and key findings was extracted. Information about the sustainability of the program and limitations identified by researchers was also extracted by authors (JB, RG, FJD).

Data analysis.

We synthesized data extracted from included articles and presented results to highlight the format, duration, and topics covered of program interventions to strengthen SRH research in LMICs. We organized information about primary outcomes into themes and summarized how SRH research capacity was sustained after program completion.

Results

Program characteristics

A total of twenty-four articles were included in the scoping review. The PRISMA flow diagram is shown in Fig 1. Fifty-one articles found through hand searching of reference lists were screened, but none were deemed appropriate for inclusion. While the search was inclusive of non-English articles, none were included in the final review because they did not meet inclusion criteria.

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Fig 1. Summary of the number of article exclusions at each stage of this scoping review of interventions in low- and middle-income countries in 2011–2023.

This diagram is based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines [24, 51, 52].

https://doi.org/10.1371/journal.pgph.0003789.g001

Out of the twenty-four included articles, eleven focused on countries within Africa [30–40]. The authors also focused on countries within Asia [41–43] and South America [44–46]. One article focused on Oceania (Papua New Guinea) [47], and two articles focused broadly on LMICs without indicating specific countries [48, 49]. Finally, one article focused on countries within the Middle East and North Africa (MENA) region [50].

More articles were published between 2018–2023 (n = 14) than from 2011–2017 (n = 10); this upward trend reflects a recent focus on SRH RCS in LMICs. In most publications, researchers in HICs led RCS programs. A majority (n = 10) of the studies identified themselves as case studies [30, 33–35, 40, 44, 47, 48, 53, 54]. The next most frequent classification was studies defined as mixed methods, wherein qualitative and quantitative data are presented [38, 43–45].

Principles

In terms of program design and approach, 12 studies offered in-person training on SRH topics to participants in LMICs. Face-to-face training formats included modules or workshops [11, 30, 33, 35, 38, 39, 42, 43, 50], networking opportunities at health colloquiums and conferences that offered a venue for engaging with policymakers, methodological training and definition of priority research topics and research methodology [33, 36], and lectures [46]. Six programs developed a training partnership to guide researchers [30, 34, 41, 45, 48, 54]. Some of the selected articles described programs that supported research projects through direct funding [32, 44], and one project studied researchers who had actively participated in a previously funded study [47]. One study examined the impact of a single meeting involving researchers, communication specialists, and donors [40]. Another developed a manual of research procedures [31]. Lastly, one study sought to understand the trends in reproductive health in humanitarian settings and organizational changes over time using a questionnaire [49].

Program size ranged from large groups with over two hundred participants [38, 55] to smaller groups of approximately eight participants [50]. Larger group sizes were possible because of online teaching formats. Participants also had varied professional backgrounds within allied and public health. Five studies included fellows and other early career professionals [31, 36, 47, 48, 55]. Two studies focused on participants from diverse backgrounds, such as nurses, midwives, doctors, community health workers, and public health technicians [30, 55]. One study specified working with a mix of early and advanced career professionals [54].

When considering the time frame, most of the included studies lasted less than a year, ranging from one day to eight months [35, 38, 40, 47, 49, 53–55]. Six studies lasted between one and three years [31–33, 36, 39, 42]. The longest studies lasted between four and seven years [30, 34, 41, 44, 46].

Looking at topics covered in SRH RCS programs, most studies focused on bringing research into medical practice [38, 39, 42, 45, 46, 49, 53, 55]. Six studies were interested in increasing the capacity to conduct research and collect data [30, 32, 34, 41, 43, 47], while others studied how the findings of SRH research are analyzed and disseminated [33, 44, 54]. The remaining studies focused on strengthening research and policy links [31, 35, 36, 40, 50] and proposing a framework for co-production of capacity strengthening health research [30].

Using the data extraction form (S1 Appendix), articles reporting similar primary outcomes were grouped and summarized into six themes by two of the authors. The articles generally focused on outcomes within the themes of advocacy/capacity, education, policy, project life cycle, and writing/publication (Fig 2). Most articles described outcomes within the realm of education, including incorporating research components into the curriculum in nursing, midwifery, and medical schools [34, 42, 43, 46, 55]. For those describing education outcomes, self-reported SRH research competencies increased after a three-day course of interactive lectures [46], as did post-intervention test scores after a professional development program with interactive modules [43]. We acknowledge the limitations and bias of self-reporting, and the results of studies utilizing self-reporting are likely non-generalizable. However, studies utilizing self-reporting techniques can still provide a general understanding of participants’ perspectives on the efficacy of training. Midwifery educators reported increased confidence while linking international standards and WHO competencies to midwifery school education curriculum revisions [4], and Millimouno [55] reported that blended learning using Sexual and Reproductive Health Services Management (eSSR) helped strengthen capacity in monitoring and data management. For Elmusharaf and colleagues [34], SRH education was expanded and recognized by the Ministry of Health in Sudan, while country-level initiatives, including the inauguration of a research unit, were established.

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Fig 2. Articles’ primary outcomes for this scoping review paper including literature published 2011–2023.

https://doi.org/10.1371/journal.pgph.0003789.g002

The next most popular outcome themes were advocacy for SRH policy changes and increased funding for RCS programs [32, 39, 45, 49, 53] and strengthening capacity for each part of the project life cycle [31, 45, 47, 50]. Authors also mentioned increasing publications [44, 54], policy [40], and recognizing researchers’ accomplishments to enhance motivation and productivity [41]. Seven articles also had a secondary outcome focus, three focusing on policy and the need to disseminate research findings to decision-makers [35, 44, 45].

In terms of lessons learned from SRH research interventions, researchers who authored articles often mentioned the importance of long-term engagement [30, 40, 43, 44], networking [31, 40, 41, 44, 54], and regional partnerships [37, 42, 44, 50, 54]. Five studies identified lessons about intensifying efforts to train researchers to engage with policymakers [12, 34–36, 40]. Another lesson learned was the need to sustain momentum in programs [37, 39, 49].

Not all studies that included lessons learned had formal evaluations of their SRH projects. Only 11 of the included articles described how programs were evaluated. Table 2 shows the methods used, indicators, outcomes, and conclusions of only the articles that reported project evaluations.

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Table 2. Summary of the subset of articles (n = 11) that included an evaluation of the reproductive health research capacity strengthening program described.

https://doi.org/10.1371/journal.pgph.0003789.t002

The research skills covered in RCS projects encompassed a broad range of competencies essential for conducting effective research. These skills included understanding theories of knowledge, research design, conduct, synthesis, interpretation, and utilization [30]. Additionally, the trainings covered stakeholder engagement, communication, and issues management [31], as well as specific methodologies such as concept mapping and health economics [53]. Participants were equipped with practical skills like data analysis, scientific writing, dissemination of research results, and database management [44, 54]. The training programs emphasized experiential learning, peer-to-peer interaction, and evaluation mechanisms to ensure the acquisition and application of these skills in diverse research contexts [30, 39, 42].

Few articles reported metrics or other evidence of long-term program sustainability of SRH research capacity strengthening projects in LMICs. However, most articles proposed methods for how to address sustainability after program completion. Many encouraged researchers to advocate for increased organization expenditure for training about the research process and augmented funding for research grants. Some advised incorporating SRH research into institutional strategic planning. Others recommended partnering with international experts to support researchers through the publication process. Some suggested forming regional partnerships to develop broader training plans or create sustainable capacity‐building projects [37, 42, 45, 46]. Elmusharaf [34] proposed understanding a partnership as a ‘network of action’ to achieve collectively more than as individuals and to have influence beyond the pilot site. Meanwhile, Dossou and colleagues [33] with the Network for Scientific Support in the field of Sexual and Reproductive Health in West and North Africa and Agyepong et al. suggested that supporting LMIC institutions in developing their protocols and focusing on the development of the methodological capacities and the shift of power and responsibilities is vital to long-term sustainability [30].

Regarding power dynamics and locus of decision-making, there were only three examples of south-south RCS collaboration [31, 37, 42]. In South Africa, Baron et al. from Wits Reproductive Health and HIV Institute shared lessons learned from implementing the Good Participatory Practice Guidelines for Biomedical HIV Prevention Trials across multi-party regional research consortia in several sub-Saharan African countries [31]. Meanwhile, Sriseng and Upvall highlighted the importance of their regional capacity building project between Thailand and Laos as essential to meeting sustainable development goal 3 through midwifery education [42]. In all other articles, researchers in HICs or affiliated with the WHO/UN were involved in programs to build the capacity of those in LMICs. None of the articles specifically mentioned who initiated the capacity building program. In four articles, the authors mentioned who decided what the content and process would be for RCS [37, 42, 45, 53].

Discussion

This scoping review described the format, duration, topics covered, and outcomes of program interventions to strengthen SRH research in LMICs. We also explored whether and how teams addressed the sustainability challenge after SRH research capacity program completion in LMICs. Included articles focused on outcomes within the themes of advocacy/capacity, education, policy, project life cycle, and writing/publication. Program organizers cited lessons learned recognizing the importance of long-term engagement, networking, and regional partnerships. Few articles reported on whether and how long-term sustainability was ensured. Ideally, local researchers will develop and sustain programs in their settings. When those from HICs develop programs, interventions must prioritize sustainability with local LMIC leaders spearheading the efforts after project completion [56]. Imbalanced partnerships will unlikely lead to serious sustainable capacity development in the South [57]. By LMIC researchers leading projects after completion, power imbalances can be shifted to promote sustainability. Several of these findings are in line with a commentary by a group of African researchers to concentrate on addressing research gaps that are relevant to policies and programs, carrying out high-quality and collaborative research, and translating research findings into policies and programs to achieve RCS through the synergistic commitment of global researchers, funders and organizations [58].

Gaps in the scoping review literature about how SRH research programs influence patient outcomes and health policy remain. The articles did not address gender diversity and did not mention built-in tracker systems. Even though the search strategy included non-English language articles, only articles written in English met the inclusion criteria. The English-language publications may reflect HIC-led programs’ values and decision-making power [18]. According to MoChridhe, the high costs in time and money that using English in global scholarship imposes on non-native learners inhibits information exchange and impedes public participation in research, especially in regions with the greatest need for the opportunities that engagement with global scholarship promises and where articulate voices are most acutely missing from broader global conversations [59]. None of the papers in our sample specifically addressed training investigators on publishing their research. Publication of research by local investigators is critical to share findings for broader implementation and to inform policy [28, 60]. The gap in knowledge about SRH research programs in non-English speaking areas warrants further investigation.

Furthermore, while the work in Africa is commendable, greater geographic diversity in SRH research programs would benefit researchers living in other LMICs. Most studies were conducted in Africa, possibly due to the historical focus of funding entities. This Afrocentrism renders it difficult to generalize the collective findings to LMIC settings in other geographical regions [7]. Paradoxically, external and international funding remains critical to the sustainability of research and innovation systems in many African countries [61]. Four studies did not identify limitations. To ensure transparency and allow for adaption of programs, it is necessary to mention the limitations of interventions in articles.

Just as it is essential to identify the limitations of interventions, highlighting strengths and examples of what worked well in RCS programs can be beneficial. In an evaluation of the long-term impact of the Vanderbilt Institute in Research Development and Ethics, a decade-old intensive grant development practicum specifically tailored for investigators from LMICs, authors identified key program elements that contributed to the programs’ success including a rigorous application and selection process led by LMIC partners, a curriculum based on applicable grant-writing skills, committed in-country and U.S. based mentorship teams, protected writing time, and an immersive cohort experience that provided participants with expanded professional networks [6]. These successful strategies could be translated to RCS specifically targeting SRH. Another example of what works well can be seen in the positive impact of blended courses on learners’ work behavior and organizational achievements after participating in Primary Health Care (eSSP), Management of Sexual and Reproductive Health Services (eSSR), and Research Methods (eMR) training developed and implemented by Millimouno and colleagues with the Ministry of Health in Guinea [38]. Online or blended learning opportunities for SRH RCS could be a way to reach a broader global audience, provided internet connectivity is reliable.

In the review, several articles in our sample reported on interventions as they were in progress or shortly after completion. It would be helpful for more reports to assess post-intervention progress in SRH research after a year or more. Sustainability is critical to maintaining SRH research program progress. A review of institutionalizing RCS in LMICs by Vicente-Crespo et al. [62] highlighted that three factors, equitable international partnerships, local leadership, and availability of funds, were related to greater intervention sustainability. Another way to foster the sustainability of RCS programs could be to institute an intensive mentorship programme combining hierarchical (vertical) and peer-to-peer (horizontal) mentoring strategies among young researchers, as undertaken by Balandya and colleagues in Tanzania [63]. In this RCS program, the less experienced peers received mentorship from senior researchers from a consortium of three partnering large Tanzanian health training institutions (MUHAS, CUHAS, and KCMUCo) and two collaborating US institutions (UCSF and Duke University) through mentored research awards and research training, and in turn provided reciprocal peer-to-peer mentorship as well as mentorship to undergraduate students [63].

Reported outcomes in our sample of scoping review studies were as varied as the methodology. In a review of RCS outcome indicators, Pulford and colleagues [64] found significant overlap and duplication in reported outcome indicators and identified priority focal areas, including research management and support, the attainment and application of new skills and knowledge, research collaboration, and knowledge transfer. When analyzing outcomes of SRH research programs, it is essential to keep in mind, due to differences in resources and research environments between LMICs and HICs, outcome measures commonly used in HICs, including publications in peer-reviewed journals, conference presentations, and funded grant applications, may not reflect accurately the research capacity and productivity in LMICs [6]. To move towards real inclusion in outcome indicators and global health in general, diverse voices, including the involvement of people who have historically been marginalized (i.e., women, those working in a low-income country, non-Anglophone, young people), need to be brought to the table to shape the debate and set the agenda [48, 65]. Furthermore, to move progress forward, research capacity outcomes need to be equally valued as research outputs [10], and health practitioners in HICs must strive to master the art of critical allyship and enablers rather than leading outcomes [56].

We conducted this scoping review to inform efforts to successfully implement current and future programs to strengthen SRH research programs while fostering long-term sustainability. One implication of the findings highlighted in the review is the need to foster the sustainability of SRH research programs with enduring collaborative partnerships in LMICs. Building and sustaining institutional support and individual engagement in SRH research takes time and effort. Further work is needed to incorporate long-term monitoring and evaluation into short-term training programs. From the onset, country ownership of a program needs to be emphasized along with the involvement of stakeholders, mainly the Ministry of Health, and leadership in local academic institutions.

Findings from the review are in line with the Guttmacher–Lancet Commission assertion that SRH are essential for the well-being and survival of individuals, economic prosperity, and the overall welfare of humanity [66]. Advancing SRH necessitates addressing the obstacles entrenched within legal frameworks, policies, economic structures, and societal norms and values, particularly gender disparities, which hinder individuals from attaining optimal sexual and reproductive health [66]. The legal framework and public policies hold equal significance alongside research in SRH [66]. Recent findings on the classification of abortion highlight that in countries with highly restrictive abortion laws, there is a notably higher prevalence of unsafe abortions compared to those with less stringent regulations. It is typical for LMICs to have both restrictive abortion laws and limited access to reproductive rights [67].

Across all included articles, SRH RCS programs diverged, making comparison between programs difficult. Acknowledging the power imbalances between LMICs and HICs and that the global research agenda is currently set and funded by HICs is important when reviewing SRH research programs. Shifting the power to LMICs is essential because local researchers will define research priorities appropriate to their region, develop contextualized responses to local health problems, and connect research to policy and practice [56, 65]. To support sustainability, future RCS programs could consider having the leadership begin as a collaborative effort between LMIC and HIC team members and then transition to LMIC leadership.

Conclusion

The results of this scoping review can be used to strengthen SRH research programs in LMICs. To address additional gaps, future research directions include exploring SRH research mentorship, identifying the cost of SRH RCS interventions, and how to foster institutional support for SRH research. More funds and energy must be directed toward ensuring sustainability in SRH research programs. To improve SRH in LMICs, we advocate for increasing SRH research strengthening programmatic support from funding organizations, institutions, and governments.

Supporting information