Shirin Heidari, Director and Editor-in-Chief, Reproductive Health Matters
Monica Adhiambo Onyango, Boston University School of Public Health, and RHM Guest Editor
Ethics of Conducting Research in Humanitarian Settings, Monica Adhiambo Onyango, Boston University
Reflections on Research Challenges in Humanitarian Settings, Ribka Amsalu, Senior Advisor, Emergency Health, Save the Children US
Compiling the Issue: “SRHR in Humanitarian Crises”, Sarah Pugh, Managing Editor and Advocacy Officer, Reproductive Health Matters
Research for Health in Humanitarian Crises, Anne Harmer, R2HC Programme Manager, Elrha.
On Friday November 10, 2017, Reproductive Health Matters hosted a panel entitled “Conducting SRHR Research in Humanitarian Crises: Challenges, Strategies and Opportunities,” at the annual meeting of the Inter-Agency Working Group (IAWG) on Sexual and Reproductive Health and Rights in Humanitarian Settings, held in Athens, Greece. Approximately 75-80 SRHR practitioners, researchers and policy-makers attended the session, during which RHM soft-launched its forthcoming issue #51, “Humanitarian Crises: Advancing Sexual and Reproductive Health and Rights”, ahead of publication. Many of the new issue’s contributing authors were present at the event, allowing for an important and timely exchange of insights between RHM authors, the Editorial Team, and other researchers and practitioners in the room.
The panel was moderated by RHM’s Editor-in-Chief and Director, Dr. Shirin Heidari, who provided the audience with an overview of RHM’s past and ongoing work on the theme of SRHR in humanitarian crises. This is a theme that has long engaged RHM, in both the journal and the organization’s advocacy work. Not only has it been the theme of a previous dedicated issue in May 2008, but articles that engage with issues of SRHR in conflict frequently appear in other themed issues, or as stand-alone papers. RHM has also engaged with these issues at various international fora, such as EuroNGOs and regional IAWG meetings. Before introducing the panellists, Dr. Heidari introduced the new issue, thanking the authors, the Guest Editor (Dr. Monica Onyango), the Editorial Team and Editorial Committee, and RHM’s reviewers for their contributions to the issue. Dr. Heidari also thanked the Dutch Ministry of Foreign Affairs for its generous contribution towards this project.
With this, Dr. Heidari introduced the panellists for the day, including Dr. Monica Onyango (RN, PhD, Boston University School of Public Health, Department of Global Health, and RHM Guest Editor), Dr. Ribka Amsalu (MD, MSc Senior Advisor, Emergency Health, Save the Children US), Dr. Sarah Pugh (PhD, Managing Editor and Advocacy Officer, Reproductive Health Matters); and Ms. Anne Harmer (R2HC Programme Manager, Elrha).
Dr. Onyango launched the panel with her presentation entitled, “Ethics of Conducting Research in Humanitarian Settings.” Research in such settings, she noted, can help us discern patterns, design interventions, and determine whether those interventions are working, and how they can be strengthened. She noted the central role of ethics within research, including the principle of doing no harm to the people and populations who are at the heart of the research. Research, Dr. Onyango explained, must be responsive to the needs and priorities of the community, and must assist in developing knowledge that can be used to improve the conditions of the community. Dr. Onyango outlined some of the core tenets of all research ethics, including issues such as privacy, informed consent, confidentiality, maximizing benefits and minimizing risks, protecting the data, ensuring the protection of participants and researchers, and ensuring that all participants have the right to withdraw from the research at any time, without implications.
In humanitarian settings, Dr. Onyango noted, there may be additional applications of ethical considerations, particularly amongst such vulnerable populations. She acknowledged that there may be special considerations which need to be taken in such settings, arguing that futile research should never be carried out, and that cultural sensitivity needed to be central to such work. She also noted that there may be very difficult ethical questions in these settings around incentives for research participation, in the context of high levels of vulnerability. Any research undertaken in such settings, she argued, should strive to provide immediate or direct benefits to the participants at that time. Dr. Onyango also raised the issue of capacity challenges within some humanitarian settings, in terms of in-country ethical review. She also noted the political pressures that may be placed on certain types of research or findings, particularly sensitive findings around human rights abuses, for example, or sexual and gender-based violence. Despite these challenges, there is a continuing need to strive for more research in such settings, and to continue to engage with these ethical challenges.
Not only are there significant ethical challenges involved in conducting research in humanitarian settings, but as the next presentation made clear, there are also substantial methodological challenges. In her presentation entitled, “Reflections on Research Challenges in Humanitarian Settings,” Dr. Ribka Amsalu began by reflecting on the reasons as to why so many of the studies presented over the course of the IAWG annual meeting were descriptive studies, program evaluations, and observational or quasi-experimental studies, while there were few, if any, results from randomized control trials (RCTs) presented. The realities of research in humanitarian settings do not align well with some research methodologies – for example, a proposal to conduct a RCT in the acute phase of a humanitarian emergency could raise significant practical and ethical questions for humanitarian responders. Cohort studies and longitudinal studies present their own challenges, raising questions around NGOs’ or researchers’ sustained capacity and resources over time, and whether the community in question will even be in that location in one or two years beyond the start of the study. On the other hand, cross-sectional studies, or case studies, are much more likely to be approved by NGO partners, due to their speed and feasibility in such settings. Nonetheless, Dr. Amsalu noted that there is a pressure to present a robust body of SRHR research, which we need to pay attention to.
Dr. Amsalu noted that there may be lessons to be learned from elsewhere around how to find a compromise, or balance, between the feasibility of research in humanitarian settings and the need for robust methodologies. She gave the example of the work of the Mental Health Working Group presented at the R2HC meeting earlier in 2017, in which the group endorsed a package of interventions as good practice and a body of evidence if it had been tested in two contexts and was found to show an effect measure. She posed the question to the audience as to whether this was a possible way forward for building the evidence base in SRHR research in humanitarian settings.
The operational realities also needed to be accounted for at the beginning of research design, including changes in personnel, insecurity, loss to follow-up, and how to navigate the shifts that occur on the ground when long duration studies must account for the progression from an acute crisis to protracted crisis context, and how to agree upon what is an acute versus protracted crisis, and what evidence is applicable in which response? Timelines and costs are another operational challenge for researchers working in humanitarian settings, particularly as a solid body of evidence requires a higher level of funding, and longer period of study. Dr. Amsalu also raised the issue of process versus impact studies, noting a desire within the SRHR research community for more of the latter. She noted that impact studies presented significant challenges, because mortality was thankfully a rare event and because the populations NGOs work with tend to be small. NGOs, then, tend to focus on implementation research, focused on use and quality of services, and feasibility, rather than impact. She raised the important question: Can researchers model implementation research results to predict impact on mortality? For Dr. Amsalu, the issue of dissemination was also important to consider, in relation to questions of how best to influence practice on the ground.
The third presentation was by Dr. Sarah Pugh, entitled “Compiling the Issue: ‘SRHR in Humanitarian Crises.’” This presentation offered some reflections from the perspective of the Editorial Team at RHM, in putting together the journal issue on SRHR in Humanitarian Crises. Dr. Pugh spoke about some of the conceptual challenges and debates that the Editorial Team worked through in their work on this journal issue – challenges which began even with the crafting of the Call for Papers, as the team needed to acknowledge and address some of the definitional challenges around what even constitutes a humanitarian crisis and a humanitarian response. For example, the team had to contend with questions of whether it could include papers set in contexts of chronic low-grade conflict, or poverty, or at what point did large flows of migrants (and often with mixed motivations for mobility) constitute a humanitarian crisis?
Another important issue raised through the process of compiling this journal issue was that of co-authorship. Dr. Pugh noted that many of the papers received through the Call for Papers were authored by individuals in high-income countries, or affiliated with institutions within high-income countries, even while the research was undertaken in low-income countries. She noted that while many researchers did seek to co-author or engage with local authors, others did not, and this was an important issue to consider moving forward. Dr. Pugh also spoke about RHM’s efforts to achieve geographical representation in the spread of articles published, as much as possible given submissions received, but she noted that some gaps remained, including Latin America and the Caribbean, and research in the context of natural disasters.
Further, Dr. Pugh raised the issue of quality of many of the papers that were received for this issue from authors in low-income countries, many of which showed important potential but were nonetheless too far from being publishable in a peer-reviewed journal for RHM to be able to take them forward for this journal issue. She noted that despite RHM’s efforts to provide extensive editorial comments, and connect such authors with more established researchers for mentoring, these efforts were not always successful due to our own limited capacity and the availability of potential mentors within RHM’s networks, or the time constraint of the publishing schedule of the journal issue. She asked how we can all collectively contribute to building the capacity of emerging researchers from all regions to conceptualise, undertake and write up their own research, in their own voices, and reflective of their own priorities? Finally, Dr. Pugh noted RHM’s ongoing commitment to SRHR issues in humanitarian contexts, encouraging researchers in the room to continue submitting articles on these issues.
Finally, Ms. Anne Harmer from Elhra introduced her presentation “Research for Health in Humanitarian Crises.” R2HC was established in 2013 between Elhra, the Wellcome Trust and DFID, in response to the observation that a significant amount of humanitarian response was not based on evidence. R2HC provides funding for public health research in humanitarian settings, under the NGO Elhra, which is hosted under Save the Children UK. The R2HC program emphasizes the importance of innovation and partnership in research. It tries to encourage world class research by fostering collaboration between academic and operational partners, and to encourage research that will be effectively used. Ms. Harmer echoed some of Dr. Amsalu’s questions and comments about how much evidence is enough to build a convincing body of evidence, noting that these were also issues R2HC was grappling with. She noted that there remained a dearth of robust SRHR research in humanitarian crises, a gap which R2HC is attempting to help address.
Ms. Harmer noted that aside from the R2HC grants, Elhra also tries to gather lessons learned about conducting research on health in humanitarian crises, and introduced the audience to Elhra’s Reseach Ethics Tool, which is available online. She also noted other works commissioned by Elhra, such as a study looking at appropriate research methodologies for GBV in humanitarian crises, which was produced in 2017 and is available online. Ms. Harmer then turned to a discussion about the call for funding for R2HC, including the process through which R2HC proposals are reviewed and adjudicated. She outlined the criteria for proposals, and noted that they do appreciate the specific methodological challenges of research in humanitarian crises, including many elements discussed in earlier presentations. She noted that there are still few funded proposals on SRHR in humanitarian crises, and that they encourage SRHR researchers to put in strong proposals. Ms. Harmer’s presentation effectively wove together many of the themes from the previous three presentations, raising questions around ethics, methodologies and partnerships, but also demonstrating that despite the challenges, important opportunities and resources do exist for researchers working in this field.
With all presentations at an end, the session was opened to questions from the audience, and a robust discussion followed, with members of the audience following up on key points from the various speakers’ presentations. Dr. Heidari took the opportunity to encourage researchers not just to publish results of successful research, but also not to shy away from writing up the results of research or interventions that did not work. Too often, she noted, researchers tended to want to publish or emphasize successes, while there is also much to be learned by interventions that fail to make an impact or research that falls short of its goals.
Overall, the soft-launch of the RHM’s new journal issue and the associated panel discussion presented a welcome opportunity for journal editors, reviewers, authors, researchers and practitioners to learn from each other, and share different perspectives around the challenges of researching, writing and publishing SRHR research in the context of humanitarian crises. Through the panel and subsequent discussions, RHM was able to further build its community and networks, and pave the way for future collaborations in this field.