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Background Humanitarian settings often present unique scientific challenges and conditions that distinguish them from standard research settings. While a number of these challenges are faced in both standard settings and humanitarian settings, factors unique to humanitarian settings such as inaccessibility and time sensitivities further exacerbate the effects of these challenges. This analysis focuses on experiences in post-disaster contexts such as Indonesia and India following the 2004 Indian Ocean Tsunami, the Philippines following Typhoon Haiyan in 2013, and Nepal following the 2015 earthquake. Discussion Particular issues that we faced in undertaking research in post-disaster settings include challenges with uncharted ethical and cultural considerations, non-standardised administrative methods for record keeping, data sharing and dissemination. While these issues are not unique to post-disaster humanitarian settings, the time-sensitive nature of our work exacerbated the effects of these concerns. Relying on local partners and making quick decisions to tackle issues is imperative for navigating both foreseen and unforeseen challenges. While pre-emptive action to address these concerns is the most efficient means to expedite research protocols, adaptability and contingency planning are key components of practical research implementation in dynamic situations. Conclusions Research is not always a priority in humanitarian settings, so innovative methods are necessary to conduct meaningful and situationally appropriate research in these venues. By understanding available resources, local culture, and political considerations and working efficiently and decisively, we can begin to jump hurdles associated with epidemiologic research in humanitarian settings.

Background Health insurance was considered as the third global health transition which can increase access to health care services by eliminating monetary obstacles to maternal health care use, particularly in emerging nations. Hence, this study aimed to assess the association between health insurance enrolment and maternal health care service utilization among women in Ethiopia. Methods A cross-sectional study was conducted using the 2016 Ethiopia Demographic and Health Survey (EDHS) data set. About 4278 mothers who had delivered at least one child in the last five years of the survey were selected in the study. Multivariate logistic regression analysis was performed to measure the relationship between health insurance enrolment and maternal health care service utilization by controlling confounders An adjusted odds ratio with a 95% confidence interval and p -values < 0.05 were well-thought-out to state the imperative association. Results The overall health insurance coverage among the women was 4.7%. About, 18.1% of women from households in the poorest wealth quantile had no health insurance coverage for maternal health care services. Moreover, 84% of women lived in a rural area did not enclose by health insurance. According to multivariate logistic regression, the likelihoods of ANC utilization were 1.54 times (AOR: 1.54; 95% CI: 1.06–2.25) higher among mothers who were enrolled in health insurance compared to their counterparts. In the same vein, the likelihoods of been attended by a skilled birth attendant were 1.84 times (AOR: 1.84; 95% CI: 1.1–3.08) higher among mothers who were enrolled in health insurance. Conclusions This study has shown that women enrolled in health insurance were associated with skilled delivery and recommended ANC utilization than women who did not enroll in health insurance. Health insurance enrolment enterprises must be available to all pregnant women, particularly those of poorer socioeconomic rank.

Background Provision of safe water, sanitation, and hygiene (WASH) to affected populations in humanitarian emergencies is necessary for dignity and communicable disease control. Additional evidence on WASH interventions is needed in humanitarian settings. Between 2008 and 2019, we completed six multi-country, mixed-methods effectiveness studies in humanitarian response on six different WASH interventions. In each evaluation, we conducted: key informant interviews; water point observations and water quality testing; household surveys with recipients, including survey and water quality testing; focus group discussions; and/or, secondary data analysis. The research questions were: “What is the effectiveness of [intervention] in reducing the risk of diarrhea/cholera transmission; and, what programmatic factors lead to higher effectiveness?” Discussion In all six multi-country, mixed-methods evaluations, policy-relevant outcomes were obtained. We found, in our individual research results, that: interventions could reduce the risk of disease in humanitarian contexts; this reduction of risk did not always occur, as there were large ranges in effectiveness; and, implementation factors were crucial to intervention effectiveness. When collaboratively reviewing our research process across evaluations, we found strategies for successfully conducting this research included: 1) working with partners to identify and evaluate programs; 2) rapidly obtaining approvals to deploy ; and, 3) conducting research methodologies consistently . Personal connections, in-person communication, trust, and experience working together were key factors for success in identifying partners for evaluation. Successes in evaluation deployment occurred with flexibility, patience, commitment of adequate time, and understanding of processes; although we note access and security concerns in insecure contexts precluded deployment. Consistent and robust protocols, flexibility, and a consistent researcher on the ground in each context allowed for methodological consistency and high-quality results. Conclusions In conclusion, we have found multi-country, mixed-methods results to be one crucial piece of the WASH evidence base in humanitarian contexts. This is particularly because evaluations of reductions in risk from real-world programming are policy-relevant, and are directly used to improve programming. In future, we need to flexibly work with donors, agencies, institutions, responders, local governments, local responders, and beneficiaries to design safe and ethical research protocols to answer questions related to WASH interventions effectiveness in humanitarian response, and, improve WASH programming.

Background Turkey hosts nearly four million refugees and 99% live in urban areas. Research in urban settings pose different challenges and opportunities than research in refugee camps. In this article, we aimed to share the challenges and experiences we encountered in a mixed-methods study to assess mental health problems and barriers to accessing mental health care among refugees in urban areas of Turkey. Discussion In our case, the main challenges in conducting research with refugees were collecting data from a highly traumatized population, difficulties with contacting undocumented asylum seekers including trust issues and the fear of deportation, the risk of secondary traumatization among data collectors, and the bureaucracy during study approval processes. Targeting a representative sample was not feasible, because of the lack of publicly available demographic data on a district level, presence of undocumented asylum seekers and high mobility among the refugees. Although respondents with significant psychological symptoms were routinely referred to available mental health services, we were able to do less for unregistered refugees with problems in accessing health care. Language/alphabet differences and differing dialects of Arabic posed another challenge in both translation and administration of the scales. Based on cultural characteristics, a gender-balanced team was used and the interviewers were gender-matched whenever needed. Also, the research team had to work after work hours and during weekends to be able to interview male refugees, since most refugee men were at work during working hours and most days of the week. Conclusions The research team’s experience showed that refugee population characteristics including level of trauma, language, culture, gender, legal status, and urban setting characteristics including places of living, mobility, availability of publicly available demographic data, and outreach-related barriers lead to different challenges and ethical responsibilities of researchers and affect the research costs in terms of time, human resources and finance. Even in a host country with geographical, religious and cultural proximity to the refugees, profound challenges exist in conducting mental health research in urban settings. Learning from previous experience and collaborating with local researchers and institutions are vital for better public health research and practice outcomes.

Background Globally, one in four children lives in a country affected by armed conflict or disaster often accompanied by exposure to a range of adversities including violent trauma and loss. Children involved with armed groups (often referred to as “child soldiers”) typically exhibit high levels of mental health needs linked to their experiences. The Longitudinal Study of War-Affected Youth (LSWAY) in Sierra Leone is a seventeen-year prospective longitudinal study of the long-term effects of children’s experiences in the country’s eleven-year (1991–2002) civil war on their adult mental health and functioning in addition to exploring the potential mechanisms by which intergenerational transmission of emotional and behavioral disruptions due to war trauma may operate. LSWAY illuminates how war-related and post-conflict experiences shape long-term adult functioning, family dynamics, and developmental outcomes in offspring. Discussion The LSWAY study utilizes mixed methodologies that incorporate qualitative and quantitative data to unpack risk and protective factors involved in social reintegration, psychosocial adjustment, parenting, and interpersonal relationships. To date, study findings demonstrate striking levels of persistent mental health problems among former child soldiers as adults with consequences for their families, but also risk and protective patterns that involve family- and community-level factors. This case study examines the course of LSWAY from inception through implementation and dissemination, including building on the study results to design and evaluate several intervention models. Conclusion The case study offers a unique perspective on challenges and field realities of health research in a fragile, post-conflict setting common in the context of humanitarian emergencies. LSWAY findings along with lessons learned from the field can inform future research as well as intervention research and implementation science to address the mental health and development of war-affected young people. With four waves of data collection and a planned fifth wave, LSWAY also provides rare insights into the intergenerational effects of humanitarian crises on children, youth, and families across generations.

Background Evidence of ‘what works’ in humanitarian programming is important for addressing the disruptive consequences of conflict and forced displacement. However, collecting robust scientific evidence, and ensuring contextual relevance, is challenging. We measured the biological, psychosocial, and cognitive impacts of a structured psychosocial intervention, implemented by Mercy Corps with Syrian refugees and Jordanian host-community youth. In this paper, we present a case analysis of this evaluation study and reflect on the scientific contributions of the work, the challenges experienced in its delivery, and the strategies deployed to address them. Discussion We identified challenges with respect to study design, methods, and dissemination: these included the logistics and acceptability of implementing a randomized controlled trial in a humanitarian context, the selection and refinement of culturally-relevant research tools and community-based practices, and the dissemination of results to multiple stakeholders. We demonstrated beneficial and sustained impacts on self-reports of insecurity, stress, and mental health; developed a reliable and culturally-relevant measure of resilience; experimentally tested cognitive skills; and showed that levels of cortisol, a biomarker of chronic stress, reduced by one third in response to intervention. Using stress biomarkers offered proof-of-concept evidence, beyond self-reported data: interventions targeting mental health and psychosocial wellbeing can regulate physiological stress in the body as well as improve self-reported mental health and wellbeing. We built constructive dialogue between local communities, scholars, humanitarian practitioners, and policy-makers. Conclusions Our work shows the value of rigorous research in humanitarian settings, emphasizing relevance for local communities and meaningful ways to build research ownership. Findings encourage the adoption of cognitive measures and stress biomarkers alongside self-report surveys in evaluating programme impacts. High-quality scientific research with youth can be feasible, useful, and ethical in humanitarian settings.

Background The 2014–2015 Ebola epidemic in West Africa became a humanitarian crisis that exposed significant gaps in infection prevention and control (IPC) capacity in primary care facilities in Sierra Leone. Operational partners recognized the national gap and rapidly scaled-up an IPC training and infrastructure package. This prompted us to carry out a mixed-methods research study which aimed to evaluate adherence to IPC practices and understand how to improve IPC at the primary care level, where most cases of Ebola were initially presenting. The study was carried out during the national peak of the epidemic. Discussion We successfully carried out a rapid response research study that produced several expected and unexpected findings that were used to guide IPC measures during the epidemic. Although many research challenges were similar to those found when conducting research in low-resource settings, the presence of Ebola added risks to safety and security of data collectors, as well as a need to balance research activities with the imperative of response to a humanitarian crisis. A participatory approach that attempted to unify levels of the response from community upwards helped overcome the risk of lack of trust in an environment where Ebola had damaged relations between communities and the health system. Conclusion In the context of a national epidemic, research needs to be focused, appropriately resourced, and responsive to needs. The partnership between local academics and a humanitarian organization helped facilitate access to study sites and approvals that allowed the research to be carried out quickly and safely, and for findings to be shared in response forums with the best chance of being taken up in real-time.

Background Humanitarian crises, such as armed conflict, forced displacement, natural disasters, and major disease outbreaks, take a staggering toll on human health, especially in low-resource settings. Yet there is a dearth of robust evidence to inform the governments, non-governmental organizations (NGOs), and other humanitarian organizations on how to best respond to them. The Fogarty International Center of the U.S. National Institutes of Health commissioned a collection of Research in Practice articles that highlights the experiences of scientists conducting research in the context of humanitarian crises. Unlike traditional research papers, the case analyses in this collection go beyond what research was completed and focus on why the research was important and how it was conducted in these extremely challenging settings. Discussion The papers selected for this collection span 27 countries, cover a broad range of humanitarian crises, and discuss a wide variety of disease and health risk factors. Of the 23 papers in the collection, 17 include an author from the affected country and five papers were authored by humanitarian NGOs. Throughout the collection, 43% of the authors were from low- and middle-income countries. Across the collection, some general themes emerged that are broadly applicable. Importantly, there is a clear need for more, high-quality research to address evidence gaps. Community engagement, already a key element to global health research, was highlighted as especially important for research involving populations dealing with severe trauma and disruption. Partnership with humanitarian actors, including local governments, local and international NGOs, and UN agencies, was found to be a critical strategy as well. Conclusion A variety of audiences will find this collection useful. Global health educators can utilize papers to facilitate discussion around public health practice and equitable partnerships, among other topics. Humanitarian response organizations may use the collection to consider how research may inform and improve their work. Global health researchers, funders, and other stakeholders may use the collection to stimulate dialogue around key scientific research questions and better appreciate the importance of conducting research in humanitarian crises in the context of achieving broader global health goals.

The protection and support of breastfeeding is the most effective intervention to prevent child morbidity and mortality especially in humanitarian crisis. During the Palestine-Israel conflict healthcare services are understaffed and lack basic resources, with frequent power cuts and stock-outs of essential drugs and equipment. This case study seeks to answer the questions: (1) How does the protracted crisis in Gaza affect the breastfeeding practices of the most vulnerable population; and (2) What is the role that midwives can play in improving breastfeeding practices? The study was conducted using a mixed method approach with quantitative and qualitative methods. Purposeful selection of women and children was conducted utilising eligibility criteria, women with children less than 2 years of age were included. All the respondents were asked if they agreed to participate in the survey. A total of 63% practice early initiation of breastfeeding and 42% confirmed that their new-borns were given liquids other than breast milk during the first 3 days of life. Fifty percent of mothers addressed breast milk insufficiency by drinking additional fluids and 40% by using infant formula. Only 18% of women said that they received breastfeeding information during contact with health professionals throughout labour, delivery, and subsequent post-natal care visits. Many mothers during the focus group discussions (FGDs) confirm using milk to top up or replace breast milk. Myths and misconceptions around breastfeeding remain, while women do access antenatal care services and deliver in the health facilities. There is a need to a) adapt the recommendations of the operational guidance for infant and young child feeding in emergencies (IYCF-E) in the Gaza strip, to protect, promote and support breastfeeding and b) include skilled breastfeeding counselling in the pre-service and in-service training for midwives. Lessons learned included the importance of a) allocating additional research time, to account for interruption b) daily coordination with security officers to ensure safe access to localities c) identification of extra sites, in case of conflict escalation d) training of additional enumerators in case conflict escalation e) negotiation with authorities to ensure compliance with requirements.

Background Two devastating sequential hurricanes impacted Puerto Rico during September of 2017. The hurricanes were traumatic and created social and ecological upheaval throughout Puerto Rico, and subsequently in communities of Central Florida where affected Puerto Ricans migrated. The 2017 hurricane season exposed and exacerbated previous long-standing socio-political, economic, environmental, and health crises, generating a humanitarian emergency in the country. The consequences of these human-ecological disasters destroyed much of Puerto Rico’s residential and environmental infrastructure, displacing thousands of people and resulting in an unprecedented migration to the United States. We report on the lived experience of the investigator team and partnership in conducting community-based formative research subsequent to this disaster, research that aimed to identify salient issues relating to the impact of Hurricanes Irma and María on Puerto Rican communities both in Puerto Rico and in Central Florida. Discussion The challenges faced during the conduct of this research include but are not limited to (1) emotional distress of participants and team members, (2) access to affected populations, and (3) precarious environmental factors, such as unstable infrastructure. To address these challenges, the researchers applied a Critical Medical Ecological paradigm along with qualitative methods to assist constructing explanatory models while obtaining internally-valid (from the community perspective), cathartic narrative accounts of the lived experience of hurricane survivors. The experience of the research team may help inform other investigators conducting applied research during a humanitarian crisis. Conclusion Lessons learned in this research included: (1) usefulness of applying the Critical Medical Ecological model in the development of the project, (2) incorporating participation and methods that prioritize authenticity, (3) understanding the trauma experience and using study methods sensitive to it, and (4) innovating with best approaches to conduct the study given the challenges in post-hurricane Puerto Rico. These lessons could provide new insights on how to conduct in-depth participatory health research with community members who have been traumatized and – often – displaced. This research also demonstrates the value of pre-existing partnerships, critical consciousness in the field team, and medical ecological modeling as experiential for organizing complex, inter-related, multi-level variables that explain community and individual impact of environmental disasters.