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Table of Contents
FIELD REPORT
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 46-53

Operational and ethical challenges of applied psychosocial research in humanitarian emergency settings: a case study


1 Psychologist and PhD Candidate at Action Contre la Faim Paris, University Paris Descartes Sorbonne, Paris, France
2 PhD, MSc, Psychologist and Senior Advisor Mental Health and Care Practices Sector at Action Contre la Faim, Paris, France
3 MCF-HDR, Psychologist at Clinical and Psychopathology Laboratory, Psychology Institute, University Paris Descartes Sorbonne, Paris, France
4 Professor and Psychiatrist at Adolescents Unit, Hospital Cochin, Child and Adolescent Psychopathology Unit, Clinical and Psychopathology Laboratory at Research Unit Inserm, Paris, France

Date of Web Publication28-Mar-2018

Correspondence Address:
Elisabetta Dozio
Action Contre la Faim Paris and University Paris Descartes Sorbonne, Paris
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.1097/WTF.0000000000000158

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  Abstract 


Interventions on mental health and psychosocial wellbeing have been largely implemented in low and middle income countries. In order to adapt the support offered, an increasing number of applied research projects in mental health and psychosocial support have been conducted. However, while challenges arising can be related to the specificity of the mental health and psychosocial sector, within a broader perspective they are also strongly linked to difficulties of access to beneficiaries, security and protections issues, and competence of staff. Research priorities and guidelines have the objective of providing recommendations to ensure a framework of best practice for research during emergencies. Therefore, this article presents and discusses operational and ethical challenges of research conducted during an emergency, as implemented by the international nongovernmental organisation Action Contre la Faim.

Keywords: Central African Republic, ethical challenges, low and middle income countries, psychosocial research


How to cite this article:
Dozio E, Bizouerne C, Feldman M, Moro MR. Operational and ethical challenges of applied psychosocial research in humanitarian emergency settings: a case study. Intervention 2018;16:46-53

How to cite this URL:
Dozio E, Bizouerne C, Feldman M, Moro MR. Operational and ethical challenges of applied psychosocial research in humanitarian emergency settings: a case study. Intervention [serial online] 2018 [cited 2018 Apr 26];16:46-53. Available from: http://www.interventionjournal.org/text.asp?2018/16/1/46/228769




  Introduction Top


Mental health and psychosocial suffering are a growing public health concern and finding ways to address these concerns is crucial for the wellbeing of society. In 2002, the World Health Organization (WHO) reported that more than 450 million people worldwide suffer from mental disorders, or from psychosocial problems, while the magnitude of the mental health burden remains mismatched in terms of size and effectiveness of the response (WHO, 2002). This gap between treatment and magnitude affects at least two-thirds of the populations con­cerned (Kohn et al., 2004). Further, the size of the gap varies across regions and is known to be bigger in low and middle income countries (LAMICs), where neither adequate treatment nor services are available (Wang et al., 2007).

The first report from the WHO Mental Health  Atlas More Details project of the Department of Mental Health and Substance Abuse published in 2001 and updated in 2014 (WHO, 2015) had the aim of collecting, compiling and disseminating data on mental health resources. They confirmed that, in LAMICs, mental health resources are both insufficient and inefficient. In 2007, the first Lancet series on global mental health called on the global health community, governments and donors to scale up the coverage of services for mental disorders (Lancet Global Mental Health Group; Lancet, 2007) especially in low and middle income countries (Saraceno et al., 2007). This led to the creation of the Movement for Global Mental Health, a network whose aim is to improve services for people with mental health and psychosocial problems worldwide, but especially in countries where such services are absent or very limited.

As a result, more interventions on mental health and psychosocial support (MHPSS) and wellbeing have been implemented in LAMICs in the last decade. However, despite the increase in the number of actions, little evidence has been provided for the efficacy of the interventions or approaches. This has led to a call for strong monitoring systems to measure the impact of psycho-social interventions and underlined the need for further research in the field (Tol et al., 2011a).

Mental health and psychosocial support research challenges

The focus on research in LAMICs highlighted the specific case of humanitarian interventions, where the need to find solutions for MHPSS problems is greater and more complex. However, operational and ethical issues go beyond global mental health questions.

A ‘complex emergency’ is defined as ‘a humanitarian crisis which occurs in a country, region, or society where there is a total or considerable breakdown of authority resulting from civil conflict and/or foreign aggression; a humanitarian crisis requiring an international response which goes beyond the mandate or capacity of any single agency’ (Inter-Agency Standing Committee; IASC, 1994). Emergencies include natural disasters, manmade disasters (including environmental disasters, conflict, wars and armed conflict), and epidemics.

It is well recognised that such situations seriously affect the mental health and psychosocial wellbeing of the populations concerned. For this reason, interventions which aim to support affected communities in strengthening their psychosocial resilience have been promoted and implemented. In order to inform or adapt these approaches, an increasing number of applied research projects have been conducted in MHPSS.

Guidelines focusing on the ethical aspects of research in MHPSS have been developed with the aim of providing recommendations to ensure ethical principles are respected, and to promote standards of best practice for MHPSS researchers during emergencies (IASC, 2014). The guidelines underline the need to consider all principles of a comprehensive framework which covers the six key areas of the research process: research purpose and benefit; analysis of ethical issues; participation; safety; neutrality and study design. The recommendations take into con­sideration the fact that it is impossible to guarantee the successful implementation of all of these principles in every study, as the reality of research conducted in emergencies is complex.

In addition, priorities in mental health and psychosocial support in humanitarian settings have recently been denned (Tol et al., 2011b). These priorities can be broken down into five categories: ’the prevalence and burden of mental health and psychosocial difficulties in humanitarian settings; how MHPSS implementation can be improved; evaluation of specific MHPSS interventions; determinants of mental health and psychological distress; improved research methods and processes’ (Tol et al., 2012, p 25).

Challenges in operational research for nongovernmental organisations

While MHPSS research in emergencies still faces many challenges, the great majority of obstacles are encountered in operational research throughout humanitarian fields in general. In an article on operational research in LAMICs, the nongovernmental organisation (NGO) Medecins sans Frontie’res (MSF), showed that operational research is fundamental to the health sector in order to improve programme outcomes, and hence services, to target populations (Zachariah et al., 2009). However, this kind of research, even if incontestably relevant for programme implementation, faces huge challenges when NGOs are directly involved.

In fact, MSF argues that NGOs should be the direct implementers of research projects as they are better able to access the most difficult zones within humanitarian disaster areas. In addition, NGOs can be the first beneficiaries of the results, as they can immediately use the recommendations to improve their practices. NGOs also play a preeminent role in influencing national policies and can consequently support the adoption of new findings and change practices. Unfortunately, in most cases, NGOs do not have the same technical capacity as academic institutions for project design and rigorous data collection and monitoring. Even when NGOs are supported by scientific and/or academic partners, the technical difficulties in project design and data collection are still a challenge. The nature of emergency operation projects is to be oriented to immediate actions with a flexible approach to adapt to changes in the environment. Whereas a research project needs to be stable and organised to allow precisely monitored phases of data collection and analysis. This is not always possible within humanitarian emergency contexts, where change can happen not only very rapidly, but also frequently during any research period. Additionally, their lack of expertise and the inevitable operational difficulties may discourage many NGOs from undertaking more research, despite the real value of their contribution. Herein we present a research project implemented by the international NGO Action Contre la Faim (ACF)1. The site chosen for the research was the Central African Republic: a humanitarian context affected by political crisis since 2013. To investigate the impact of migration on mother/child trauma transmis­sion, it was decided to extend data collection to Cameroon and Chad, where some of the Central African population has migrated and currently lives in refugee camps.

Very little or no literature is available on the psychological factors specific to the Central African Republic population. A previous article focused on an integrated psychosocial support and food security project implemented during an emergency contains information on some traumatogenic factors and mother/child relationships (Dozio et al., 2016b). That article highlighted the impact of the war context on the mothers’ psychosocial wellbeing, on poor child care practices and on the availability of a parental system. More research and assessment are clearly needed to understand this population and, in particular, cultural markers. Therefore, the aim of this article is to describe and discuss the operational and the ethical challenges faced by NGOs when conducting research and to help improve care through better designed humanitarian interventions.


  Mother to child trauma transmission in the Central African Republic, Cameroon and Chad: a case study Top


Project description

Within humanitarian contexts, situations of extreme emergency, such as natural disasters or armed conflict, are characterised by individual and collective trauma. In terms of addressing the needs of vulnerable populations, it is important to understand the different mechanisms of transmission of trauma and its impacts on children, with a particular focus on infants. In 2014, the NGO ACF started a research project to understand the mother-to-infant trauma transmission process and to analyse how external traumatic events affect the mother’s capacity to respond effectively to her baby’s needs. We hypothesised that mothers affected by posttraumatic stress symptoms show limited availability to respond o their infants’ needs and that this will be reflected in poor or inappropriate mother/infant interactions (Dozio et al., 2016a). The primary objective of the research was to identify certain aspects of the management of traumatised patients and thereby improve care through better designed humanitarian interventions.

Participants

Participants in the study included 24 mother and child dyads, in which the mothers had been exposed to traumatic events (according to criterion A2 of DSM IV) in the absence of the baby or before his/her birth, previously, or during pregnancy. The children were aged between 1 and 30 months. Dyads in which the children themselves had had a direct traumatic experience were excluded. Mothers with severe mental retardation, addiction or psychosis were also excluded. The dyads were recruited via psychosocial support programmes implemented by ACF.

Research design and methods

The methods used in this research are qualitative, descriptive and observational, focused on the mothers’ discourse while observing her interaction with the baby. The mothers were invited to participate in semi structured interviews in the presence of their infants. The aim was to observe the mother and child relationship and the reactions of the infant during the narrative of the traumatic event experienced by the mother. The interview was videotaped to allow the microanalysis of mother and child behaviours and their interactions.


  Measures Top


The impact of the traumatic events and posttraumatic stress disorder symptoms of the mothers were screened using the Impact of Event Scale revised (IES-R) questionnaire (Weiss & Marmar, 1997). The scale consists of a list of 22 self-reported items assessing the perceived distress caused by traumatic events. The literature shows that the IES-R scale is used to measure posttraumatic stress disorder (PTSD) symptoms in many cultures throughout the world (Weiss, 2007). Symptoms of depression and anxiety were measured using the Hospital Anxiety and Depression scale (HAD) (Zigmond, & Snaith, 1983). This instrument has been validated in both medical and general populations, and a recent systematic review of screening tools for common mental disorders in LAMICs (Ali et al., 2016) broadly recommends using the HAD scale for depressive and anxiety disorders as it has been validated in multiple settings.

The semi structured interviews and the psychological scales were carried out by one principal investigator and two ACF programme managers. All three are expert psychologists with many years experience of psychosocial programmes in the humanitarian field. As the investigators did not speak the local language, a local psychosocial worker was used as interpreter in the interviews. We examined the mechanisms of transmission of trauma between the mother and her infant by observing their verbal, corporal and visual interactions. These observations combined with micro-analysis of the interactions (Stern, 2004) made it possible to observe what happens when a mother describes her traumatic memories in the presence of her infant and the influence of these memories on mother/ infant interactions.

We analysed three, three minute sequences:
  1. Sequence 1: a neutral initial sequence ‘before the traumatic narration’ used as the baseline for comparison with the two other sequences;
  2. Sequence 2: ‘the traumatic narration’ where mothers were invited to narrate their traumatic events at the level of detail they were able to tolerate and to describe its effect on their present life;
  3. Sequence 3: ‘after the traumatic narration’ began with the first mention by the mother of a neutral subject. The aim of these questions was to stabilise the mothers’ emotional state.


Mother and infant behaviours were coded using the open source multimedia annotator Elan3, version 4.9.3 (Sloetjes, & Wittenburg, 2008) by the principal investigator and a randomly selected sample of 25% of interviews were coded by a group of expert psychologists in order to measure the inter-rater reliability (Cohen’s Kappa), which was satisfactory (k = 0.686).


  Results Top


During the traumatic narrative, the mothers appeared to be emotionally affected by their memories. They looked significantly absent, smiled less, looked less at the interviewer and concentrated less on actions towards the infant; mothers touched and looked at the infant significantly less than in the other sequences. This suggests that the mothers have difficulty in properly assessing the verbal and nonverbal expressions of infant arousal because they are preoccupied with their own emotional state. The infant experiences this sudden lack of proper responses from his/her mother when she faces events or thoughts that trigger trauma memories, which has an impact on his/her perception of his/her own emotional status. These mechanisms may explain how traumatic events experienced by the mother can be transmitted to the infant.

Place in MHPSS research priorities

According to the priorities denned by Tol et al. (2011b), this research can be classified as: ‘determinants of mental health and psychological distress’ since the main objective was to understand the determinants of ‘mother to baby trauma transmission’. The data we collected during the study and the results obtained could help improve support for mother/ infant dyads through programmes focused on the early strengthening of mother/infant interactions and improving the mother’s psychological wellbeing, as well as parenting skills. For these reasons, the type of the recommendations made as a result of this research can be classified as: ‘how MHPSS implementation can be improved’.


  Ethical and practical challenges Top


While during emergency contexts, it is simply not possible to respect all ethical recommendations contained in the IASC document, this research project nevertheless answered several ethical questions. As detailed in [Table 1], it was possible to follow the majority of recommendations, even though this was possible only after first overcoming problems due to operational constraints related to the specific context.
Table 1: Ethical recommendations followed

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Of the six ethical recommendations listed in [Table 1], only two of the recommendations (‘Research purpose and benefit’ and ‘Neutrality’) did not involve any challenges. According to the recommendations, research within humanitarian settings should fulfil a real gap in knowledge, but only in cases where research questions cannot be answered within a nonemergency setting. The general question about mother-to-child trauma transmission can be investigated in a nonemergency setting, but the final objective of this research is to improve care of mothers who have experienced complex traumatic events within a humanitarian context, and to limit impact on child development. This was the reasoning behind why we needed to understand the specificity of psychological trauma transmission in populations who live continually in an emergency situation.

This study was conducted in a conflict zone and the research design is clearly non-aligned. Non-discrimination in participant selection is demonstrated by the choice to interview mothers and babies from each side of the conflict, Christian and Muslim. Both religions were represented and the protocol specified access to both populations.

A plan on how to ethically exit from the research area was not denned in the protocol. The only reasons mentioned for the exit or the abandonment of the study were safe access to participants and the security situation in the countries where the research was undertaken. As this study was not expensive, it was entirely funded by ACF. Research interests are transparent in the sense they are focused on improving knowledge on trauma transmission and subsequently, based on results, on adapting psychosocial interventions for mother and babies. The main challenges were related to participation and safety. There were also a few difficulties linked to ‘Ethical review’ and ‘Research design’.

Participation

One challenge under the ‘Participation’ segment was that real involvement of the community was not taken into consideration in the research design, which had been done in Europe in collaboration with academic institutions. This choice was justified, given the need to be operational in a short time to be able to investigate the impact of the ongoing crises on mother to child trauma transmission. Additionally, communities and authorities in the study area had been extremely weakened by continuous violence and insecurity, and it was, therefore, not possible to collaborate with them at an early stage of the research project.

The second challenge related to ‘Participation’ was linked to participants’ selection and consent.

Recruitment was easy as participants were part of psychosocial programmes already implemented by AGE A consent form was presented to each participant and they found it to be clear. Recruitment and agreement to participate, therefore, did not raise any issues, but two other challenges arose in terms of consent. The ease with which people shared their stories in front of a camera and that all mothers recruited agreed to participate in the study raised the issue of whether the research goal and the purpose of the interview had been fully understood. For example, despite many explanations about the purpose of the study, some mothers took part because they expected material assistance.

Another challenge arose in terms of the subgroup of participants living in Cameroon, as the role of the husband in the women’s lives had been underestimated. As the women were unable to decide on their own whether to participate in the interview, they needed time to obtain the authorisation from their husbands. This lengthened the process and resulted in missed opportunities to interview as the principal investigator had to leave the area before the mothers had obtained consent.

Safety

Risks to the participants were minimised even though in the Central African Republic taking all necessary measures to protect participants and investigators was quite challenge. In the displaced camps in the Central African Republic it was difficult to find a confidential place for the videotaped interview, without exposing the participants. Also, it was not always easy to fix an appointment with mother and baby dyads for a specific day, as the security situation in the Central African Republic was extremely volatile for some months. These difficulties in getting out into the field made data collection challenging and limited the sample of participants. This also impacted the principal investigator. Originally, it had been planned that the interviews with the principal investigator and the mother/baby dyads was to occur at specific times during the two-year research period. The scheduled visits to the field, as a result, did not always occur within the optimal period for safety within the zones identified for data collection. Therefore, within the two-year period, it was only possible to tape 38 interviews, among which only 24 were eligible for data analysis as they respected the research design as defined in the protocol.

Ethical review

In an article about their Independent Ethics Review Board (Schopper et al., 2009), MSF reported that qualitative research methods are sometimes not considered to be ‘real research’ and for this reason, are not submitted to ethics review. The research conducted in our case study used qualitative methods and was undertaken as part of the ACF psychosocial projects, consequently, the women and their babies could be considered as ‘informants’ and the data collected could simply be considered statistics for monitoring and evaluation of project quality. Nevertheless, it was also decided to submit the research protocol to the Ethical Review Board in each country. The exception was Chad, where the Ethical Board was not operational at the beginning of the research. In Cameroon, it was quite simple and a positive answer was received within two months. The real challenge concerned the Central African Republic, where the approval process took more than one year. Political instability in the country was complex and created the delay. Despite these difficulties, the Board was finally able to meet to deliberate and the protocol was approved.

Research design

The final research design was of a good quality standard. To achieve this quality, the researchers first went through a feasibility stage to test and check whether data collection and the tools needed to be improved. For this reason, almost one third of interviews conducted at the beginning of the research project were excluded from the data analysis as they did not fully comply with the final protocol. Having a satisfactory research design from the outset would have enabled us to sample a larger number of mother/child dyads and consequently dispose of more statistically significant data. The nature of the study context made it impossible to use a randomised controlled trial research design. As the majority of the population had experienced the same traumatic event, it was difficult to define a control group, so the choice was made to use a qualitative method. As a psychosocial study, the research design and data analyses were subject to certain limitations due to specific challenges linked to the mental health and psychosocial domain, these are discussed further below.

Psychometric measures

Two tests, HAD and IES-R, were added to the protocol to measure anxiety, depression, and impact of traumatic events. Although these tests have been used in many different cultural contexts, they have not been validated for the specific population in our study. All the participants were illiterate, so the tests could not be self-administrated, but had to be administered by the investigators. Indeed, it is still very difficult to find scales and questionnaires that adequately measure psychological determinants in Central African populations.

Language

In psychosocial research based on interviews and discourse content analysis, language can present a real barrier. Local languages and idioms of illness are not only a problem for psychosocial research, but also the need for interpreters and consequently the impossibility of accessing the ‘real words’ used by the participants can represent a limitation in psychological interpretation and analysis. In fact, repetition, poor language, specific words used to describe facts and emotions are essential for a real understanding of psychological process. However, in this particular case study, the interviews were conducted in the presence of an interpreter who did not translate the sentences or concepts word for word, but limited the translation to the ‘general meaning’ of what the mother was saying.

Countertransference

The interpreters had a very particular role in this study as they had been exposed to the same traumatic events as the participants. In addition, just as the mother/infant dyads who were interviewed, they were still living in conditions in which they were continually exposed to stress and to the war context. Within this context, it is important to note that during the interviews, the interpreters were affected by significant counter reactions to the narrative, this in turn affected their psychic availability to translate the mothers’ stories as accurately as possible, especially when the narration ‘touched’ an intimate experience similar or linked to their own suffering. As members of a ACF psychosocial team, interpreters are technically equipped to listen to ‘traumatic’ narratives, and a staff care system guarantees clinical supervision when necessary.


  Solutions Top


Participation

Even though the communities and local authorities were not involved in the original study design and its implementation, they were directly and actively involved in the second stage, which was acceptance of the research. The ACF team in the field obtained acceptance and a real appreciation of the topic from the community, especially in terms of possible operational implications. In Chad and Cameroon, partnerships with the associations and institutions who manage refugee camps, were documented in written agreements. Coordination with the stakeholders avoided duplication of research objectives and protected participants from being solicited if they were already involved in other research or interviews with journalists, which is very common in such a context. In Cameroon, out of respect for cultural habits, family heads were asked to give their informal consent for women to participate in videotaped interviews.

An effective way to get participants and the community to take part in a study is promising to disseminate the results. This engagement was formalised in the protocol validated by each Ethical Review Board. Indeed, the results will be disseminated once all the data have been analysed by the end of 2017. The practical recommendations will include psychosocial activities for the early prevention of mother to infant trauma transmission within an emergency context. The participants who, despite our initial explanations about the purpose of the study, asked for material support at the end of the interview were referred to the projects carried out by the other sectors of ACF in the same area (such as food security and nutrition projects focused on prevention and treatment of under-nutrition as well as on strengthening resilience in the face of crises).

Safety

As this study was conducted as an integral part of ACF programmes, safety was guaranteed by a security plan drawn up based on ongoing changes in the regional context. The protection of participants was ensured by the presence of a psychosocial worker during the interview who oversaw psychological support of both mother and child. As the psychosocial worker is in direct contact with the mother as beneficiaries of psychosocial programme, this can facilitate the communication with mothers in cases of dangerous situations in order to the change the date or place of interview. This also made follow-up possible. In many cases, the research setting favoured the expression of psychological problems or of the experience of violence that had not been previously expressed. Very often in research on psychological issues, because it is research and not therapy, it allows people to express different emotions and sometimes express more because they are in a different context. Additionally, when this happened, the psychosocial worker integrated the new information and adapted the counselling approach. Psychiatric cases were excluded from the outset by the inclusion criteria. Cases of gender based violence that were revealed during the interview were referred to the specific services responsible for medical care. Confidentiality and anonymity were guaranteed by the research protocol and no videotaped material was stored in the field. The team is accustomed to respecting confidentiality clauses and related strategies, such as a relevant clause was included in their contract. The visual material will be destroyed at the end of the research project after the results have been disseminated. The identity of the participants was systematically anonymised, and in the case of communication at international congresses, the mothers’ and infants’ faces are blurred.

Discussions with community leaders and camp management managers helped to find appropriate solutions for the physical protection of participants and research team. Safe places in the camps or in health centers were available when negotiated in advance. Therefore, if the day of the appointment was considered to be too dangerous for the mother and the research team, the interview was cancelled or rescheduled. While difficult to reach people by telephone sometimes, it was always eventually possible.

Ethical review

Aside from patience, no solutions were possible to accelerate the process in the Central African Republic. Therefore, it would be better to take into account the length of time necessary to obtain validation from the beginning of the project.

Research design and issues specific to MHPSS

It was difficult to foresee all potential obstacles at the study design stage. The preliminary stage helped to take into account the measure of PTSD and linked pathologies, such as depression and anxiety, even if it was not possible to use a culturally validated scale. The scales chosen were appropriate as they were quite easy for the interpreters to understand, however, the interpreters needed training in the use of the scales, and in the meaning of single items.

Technically, the use of cameras can be complicated, all the more in ‘natural settings’. In this particular case, the use of two different cameras to follow the movements of the child during the interview may be preferable. This was not done in the present study, but would be worth testing in future research involving mothers and children.

To acquire an adequate sample, the principal investigator set up some supplementary visits to the field. It would be preferable to have an investigator based in the country/ countries where the study is to be conducted for a longer period to ensure more frequent access to participants.

The problem of accessing the ‘real discourse’ of the mother was hard to overcome. It is difficult to translate the narratives word for word because certain concepts are untranslatable, they do not exist in the target language or are transformed when translated into another language.

Nevertheless, to be sure the interpreter had reproduced the general sense of the narrative without omitting important details, we asked members of the ACF team who did not take part in the interviews to translate the traumatic narrative of the mother, word for word. This was only possible for 10% of the interviews, as it is very time consuming.

Concerning countertransference of the interpreter, an individual emotional debriefing was systematically organised after each interview, and dedicated group discussions were held with all interpreters to support them in the difficult task of listening and translating when the traumatic narratives took them back to situations that they had personally experienced.


  Recommendations Top


Based on the experience gained this study, we can make the following recommendations for future research within emergency humanitarian contexts:
  1. The main point is the context which is extremely insecure and unpredictable. Clear rules and security plans are essential to ensure the protection of the research team, participants and their communities.
  2. It is preferable to allow enough time, not only to analyse the context and the feasibility of the study, but also to obtain the authorisation of the Ethical Board and to collect the necessary data. To achieve this goal, the investigators in charge of collecting the data should be present in the field for a sufficiently long time, rather than merely short visits organised in advance.
  3. Aqualitative analysis of the cultural specificity of psychological dimensions understudy should be conducted systematically to ensure scales that have not been validated in the study context can be administered reliably. Translation and back translation should be the minimum standard before administration begins.
  4. The interpreters need training in translation for the administration of the scales and in data analysis. When possible, a word for word translation of the transcribed interviews is preferable.
  5. If the interpreters and translators them selves have been affected by traumatic and stressful events that can have an impact on their role, they need support through regular supervision and emotional debriefing. This will help them control their feeling of being overwhelmed by their emotions and ensure a better quality translation.
  6. This study was made possible by the continued presence of the NGO ACF in the same region for several years. Without a stable presence in the target country to guarantee both security and access to participants, it is better to not carry out this type of study in emergency contexts.
  7. Collaboration and agreements with local academic institutions or stakeholders with technical expertise in psychosocial topics should be encouraged when possible.



  Conclusions Top


This paper is not an exhaustive account of the ethical and operational difficulties that may be encountered by NGOs conducting operational research with a particular focus on mental health and psychosocial sectors. Although the ethical challenges are huge, this case study shows that it is possible to respect the majority of the recommendations, although improvements in all six chapters are possible and necessary. A better preliminary study would help promote good practice and limit ethical challenges. The preliminary process should promote ‘participation’ through strategies of community inclusion in several crucial phases of project design and even in identifying ethical issues linked to the specific context (Chiumento et al., 2016). From an operational point of view, the main challenges encountered were related to ‘Security’, but these are unfortunately almost impossible to predict or manage within emergency settings. As far as ‘Acceptance’ in the field is concerned, we did not experience any particular problems. This can be explained by the fact that the study was a small project using a qualitative methodology and was part of an existing psychosocial programme. ‘Acceptance’ by participants and by the community can be facilitated by recognising the strong need for psychological support for distressed people.

Despite the problems and difficulties encountered, our positive experience reinforces our belief that NGOs should not be discouraged from searching for innovative ways to answer their own questions to better respond to humanitarian needs. Despite all possible obstacles, it is necessary to continue and to progress in operational research.[22]



 
  References Top

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