Barriers and Facilitators to Engaging Communities in Gender-Based Violence Prevention following a Natural Disaster

Abstract

Humanitarian workers in disaster settings report a dramatic increase in gender-based violence (GBV). This was true after the 2010 Haiti earthquake when women and girls lost the relative security of their homes and families. Researchers from the United States Virgin Islands and the United States mainland responded by collaborating with Haitian colleagues to develop GBV-focused strategies. To start, the research team performed a situational analysis to insure that the project was culturally, ethically, and logistically appropriate. The aim of this paper is to describe how the situational analysis framework helped the researchers effectively approach this community. Using post-earthquake Haiti as an exemplar, we identify key steps, barriers, and facilitators to undertaking a situational analysis. Barriers included logistics, infrastructure, language and community factors. Facilitators included established experts, organizations and agencies. Researchers in such circumstances need to be respectful of community members as experts and patient with local environmental and cultural conditions.

Natural disasters cause significant societal disruption in the affected communities within countries and often cause massive human, environmental, and financial losses. The risk of conflict and violence following a natural disaster frequently increases as populations struggle to meet basic needs.^1,2 Humanitarian workers and researchers in disaster settings have reported a dramatic increase in gender-based violence (GBV) in households and communities.³ Verification of this increase may be derived from police reports, hot-lines, and urgent need calls for placements in shelters for women and girls assaulted in the home and larger community. Globally, however, the vast majority of survivors of violence never access formal services. Consequently, the increases reported through formal systems merely reflect the tip of the iceberg related to GBV that occurs in natural and man-made disaster settings. Few studies have adequately documented the effect of GBV on the lives of women and girls post-disaster. This limitation negatively affects the availability of protection and sanctuary services available for survivors.⁴

Following the 2010 earthquake in Haiti, a team of researchers from the U.S. Virgin Islands and the United States mainland sought to collaborate with Haitian partners to develop, implement, and evaluate strategies to prevent GBV in this limited-resource setting. The Caribbean Exploratory NIMHD Research Center (CERC) located at the University of the Virgin Islands, School of Nursing received supplemental funding from the National Institute on Minority Health and Health Disparities (NIMHD) to support the project. The CERC had collaborations with researchers and consultants with expertise in GBV working to assess and meet the needs of internally displaced people (IDPs) following disasters. The U.S. Virgin Islands are in close proximity to Haiti, being only a one-hour flight (511 flight miles) away and has a substantial Haitian immigrant community and previous history of collaboration. This proximity and existing relations and links to the Caribbean Diaspora made the CERC uniquely situated and relevant to addressing GBV and assisting the Haitian community in infrastructure and capacity-building during the post-earthquake period.

Beyond the physical devastation caused by the earthquake, Haiti was affected by multiple workforce and infrastructure losses. This manuscript describes the development of the critical collaboration between researchers and Haitian colleagues to develop a culturally relevant and ethically responsible GBV prevention and response intervention to address the safety and protection needs of women and girl survivors of the earthquake. The team began working within the six months immediately following the earthquake; the first in-country work occurred 13 months after the earthquake. This manuscript presents the early stages of the research and challenges experienced when developing the GBV prevention and response intervention. It gives an overview of the situational analysis that includes steps taken, approaches attempted, challenges encountered, and solutions found to achieve the project aims.

Haiti has a history that is complex and unique among Caribbean and Latin American countries, and this has shaped the social, political, and economic contexts for understanding the dimensions of gender-based violence and the earthquake’s devastation.⁵ Despite Haiti’s history as the country emerging from the only successful slave revolt in history and the first country in the Western Hemisphere governed by people of African descent,⁶ it has the lowest economic indicators in the Western Hemisphere with a Gross National Index per capita of 760 U. S. dollars.⁷ Government services and infrastructure are unreliable and meager in Haiti where approximately 51% of adults are illiterate.⁸ Historically, the country has been crippled by frequent natural disasters, most often hurricanes and tropical storms, which bring serious flooding and damage to towns, bridges, and roads. Basic sanitation is lacking in Haiti and related amenities lag behind those of neighboring countries.⁷

On January 12, 2010, an earthquake measuring 7.0 on the Richter scale struck Haiti. The epicenter was near the capital city of Port-au-Prince. This catastrophic event became a humanitarian crisis not only because of the magnitude of the earthquake, but also because of the high population density in the affected area, poorly constructed buildings, weak infrastructure of the country, and the centralization of Haitian services in Port-au-Prince. The vast devastation included estimates of up to 316,000 people killed, 300,000 injured, over a million displaced, and over 250,000 homes destroyed or severely damaged, with wide variation in these estimates.⁹ Many displaced families were forced to move to tent camps where few services were available; clean water, sanitation, structurally safe housing, electricity, and dependable sources of food were severely lacking. In 2012, the International Food Policy Research Institute¹⁰ reported that food insecurity in the country was extremely alarming. Currently, 48% of the population in rural areas and 75% in the urban areas had access to an improved water source;¹¹ in the two years following the earthquake, access to clean water and sanitation facilities was even worse and these poor conditions contribute to water-borne, diarrheal, and communicable diseases. Five years after the 2010 earthquake, 59% of the population continue to live below the national poverty line of $2.44 US per day; 24% live below the national extreme poverty line ($1.23 US per day).⁷ Although great progress has been made regarding housing, greater than 85,000 people remain in camps for internally displaced people.¹²

Gender-based violence in pre-earthquake Haiti

A substrate of devastation fuels GBV, which is broadly defined as “any harmful act that is perpetrated against a person’s will, and that is based on socially ascribed (gender) differences between males and females.”^{13[p. 1]} In addition to acts of sexual violence and exploitation most often associated with GBV, physical violence, psychological violence and coercion, reproductive violence—including forced pregnancy, sterilization, and abortion—constitute this devastating constellation.¹³ These acts may be perpetrated within the family or community. Gender-based violence can result in serious and often long-term physical, psychological, and reproductive health outcomes; it frequently results in disruptions within the family and social structures, stigma for the survivor, and affects productivity within a family and community. Many survivors need post-assault health services, but do not receive help or are often delayed in seeking care and treatment. Access to health services is often limited and there are few skilled providers. In addition, there is a lack of information on available health services, a knowledge gap regarding the importance of early testing for sexually transmitted infections, including human immunodeficiency virus (HIV), and fear of stigma and rejection from family members and the community if the assault becomes known.¹⁴

Before the earthquake in Haiti, GBV was a significant public health problem; 26% of all women and girls 15 years of age and older could expect to experience GBV in their lifetimes.¹⁵ This finding is consistent with global estimates of one-in-three women worldwide experiencing physical or sexual violence in their lifetimes. Social norms of behavior that condone the right of men to control women with physical and sexual violence are perceived by some men and women as acceptable.¹⁶

The persistence of GBV in communities and the lack of strategies to abate it were exacerbated following the earthquake in Haiti.^17–19 The social disorientation caused by the earthquake was compounded by the deaths, injuries, and separation of many family members. Many women and girls who were displaced into tent camps became even more vulnerable to GBV, partly because they often lost the support and protection normally provided by parents, brothers, husbands, boyfriends, and other family members. In addition, anecdotal and media reports identified several other reasons for the increase in the number of rapes in the camps: poor lighting; long walks to the bathroom that were particularly treacherous after dark; flimsy tents that were not able to be locked at night; a post-earthquake disruption in the usual societal norms of protection and community responsibility.²⁰

Initial Approach

Within six months after the earthquake, the research team organized and began developing the project with local partners. The federally-funded research project has a single group longitudinal design that included an initial assessment of the community and resources followed by a survey of 250 displaced women and girls regarding their experiences with GBV. Then, based on the assessment and survey results, an intervention aimed at reducing GBV was planned and delivered. Prior to implementing the study, the team agreed that a situational analysis—the systematic and prospective data collection and synthesis of information—was essential as the initial stage in this research project to develop a culturally and ethically appropriate GBV prevention and response intervention. Situational analysis is a tool widely used particularly in public health as it considers the macro (government and policy context), meso (infrastructure frameworks and resources) and micro (individual families and communities) factors of a condition or problem.²¹ Considering the interface of these multiple and inter-related factors is critical in shaping effective interventions. Tools of a situational analysis include exploring the broad areas of population characteristics, infrastructure, politics and policy, health needs and services, available resources, and the current state of resources.²² The situational analysis is also important to guide development of data collection tools and intervention delivery and dissemination strategies. See Figure 1.

Figure 1.

Components of the situational analysis: Macro (government, policy, culture), Meso (infrastructure, frameworks, and resources), Micro (individual, family, community).^a

^aConsidering the interface of these factors is critical in shaping effective interventions. Tools of a situational analysis include exploring the broad areas of population characteristics, infrastructure, politics and policy, health needs and services, available resources, and the current state of resources

Project team

Building a collaborative team of experienced U.S. Virgin Islands (USVI), United States (U.S.) and Haitian informants was a critical first step in the situational analysis, and this began within the first year after the earthquake. Subsequently, the research team used the evidence that existed in pre-earthquake Haiti to collaboratively develop, implement, and evaluate strategies to prevent GBV for women and girls who had survived the earthquake. The situational analysis began in the USVI and mainland United States and continued during two team visits to Haiti, occurring one year after the earthquake. Focus groups were held to help broaden the research team’s understanding of GBV in Haiti before and after the earthquake. One focus group included Haitian professionals and another included women living in tent camps.

Advisory board

Because of the devastation from the earthquake, many key leaders in GBV advocacy, nursing, and community-based programs in Haiti had lost their lives. Consequently, as the study was launched, the identification of GBV experts and organizations was further complicated by the ongoing displacement and loss of infrastructure. An initial step was to build an advisory board of Haitians living in the U.S. Virgin Islands and United States at the time who could help the team identify in-country experts and organizations as potential partners in the research. The advisory board assisted the team in making contacts with local community-based organizations; these included MADRE, an international women’s human rights organization to advance social justice; the Commission of Women Victims for Victims (Komisyon Fanm Viktim pou Viktim; KOFAVIV), a grassroots women’s group based in Port-au-Prince dedicated to providing ongoing support and services to victims of sexual violence; governmental institutions such as the Ministry of Women’s Affairs and the Ministry of Health; international non-government organizations (NGOs), such as the Catholic Medical Mission Board, which works collaboratively to bring health care services and programs, without discrimination, to people in need worldwide; the International Labour Organization, a United Nations organization that promotes social justice through labor and human rights; and multi-national organizations, such as the United Nations High Commissioner for Refugees which aims to protect refugees around the world, and the United Nations Children’s Fund (UNICEF), which focuses on long-term developmental support and short-term relief to children and mothers in need. The research team tapped the expertise of these in-country organizations regarding the context of women and girls’ lives, estimates of prevalence of GBV among displaced populations, and current capacity to effectively prevent and respond to GBV. In addition, the advisory board provided knowledge and experience in the development of the culturally and linguistically appropriate GBV prevention and response intervention that prioritized ethical approaches.

In-depth systematic review of circumstances

After the advisory board was established and potential in-country individuals and organizational partners identified, the team proceeded with the situational analysis and performed a comprehensive assessment; this critical step was designed to help the team gain a thorough understanding of the complex circumstances in the region and guide the further development of the project.²¹ This comprehensive assessment was conducted in three phases. See Figure 2.

Figure 2.

Phases of the GBV Haiti project situational analysis.

GBV= Gender-Based Violence

Phase one: Gathering information

The first phase involved the researchers working with the advisory board and was completed prior to traveling to Haiti. An in-depth and systematic review was completed, using both quantitative and qualitative data, regarding the geography, people, communities, socioeconomics, and politics of Haiti pre- and post-earthquake. Given the team’s expertise in GBV and international and public health, the team focused on identifying opportunities for interventions with survivors through existing health systems in targeted communities within Port-au-Prince. The team investigated factors that affected risk of GBV, for example, access to safe housing, education for women and children, and secure areas for displaced individuals and families to access clean water and latrines. Haitian government and organization websites were accessed, as well as governmental data and global humanitarian and development agency reports on Haiti.

From this analysis, the team identified key informants for initial contacts to identify needed information and resources for the in-country research. From the initial contacts, a snowball technique was used to identify other potential sources of expertise and in-country resources on GBV, health, and related areas. The key stakeholders assisted the team in identifying several NGOs with a long history of working in Haiti. Project reports and analyses that gave the team important foundational information related to GBV prevention and response were also pursued. Two particularly useful reports were from the International Rescue Committee²³ and the Pan American Health Organization. ²³ The International Rescue Committee had mapped the national and international actors providing GBV services in Haiti during the months immediately following the earthquake and summarized findings about health care access, health personnel and skills, shelter problems, and the unique needs of girls.²³ The Pan American Health Organization reported findings of a needs assessment performed May–June 2010 that encompassed key informant interviews with international and local NGOs and documented site visits to key GBV referral sites for survivors.²⁴ These reports helped our team and advisory board to better understand health conditions and circumstances related to GBV post-earthquake in Port-au-Prince and allowed a comparison with other areas of Haiti, the Caribbean, and globally.

Phase two: Partnership formation

The second phase of the situational analysis involved a trip to Port-au-Prince that allowed team members to hold face-to-face meetings with potential partners and begin to develop partnerships with Haitian-based NGOs, Haitian academic institutions, including schools of nursing, and other key stakeholders. Three team members travelled together, led by the principal investigator, a researcher from the U.S. Virgin Islands who has significant experience in conducting community-based and health facility-based research with survivors of GBV. She was accompanied by a U.S.-based clinician who had many years of experience in Haiti as a pediatric practitioner and researcher as well as basic skills in the Creole language. The two research team members were accompanied by a Haitian-American businessman who had established relationships with several local NGOs, academic institutions, and governmental organizations in Port-au-Prince that were willing to be initial contacts for potential collaboration regarding the research. He assisted the research team in necessary negotiations with numerous officials and authorities to gain permission to conduct the research. His expertise allowed the research team to move throughout the city with ease and advanced the researchers’ understanding of the context and challenges for women and girls displaced from their homes by the earthquake.

During the first visit to Haiti, the team focused on three aims:

1. the identification of appropriate governmental, organizational, or academic institutions that could support the process for obtaining an ethics review from an official Haitian ethics review board, which is an essential component for respectful and collaborative research;

2. the obtaining of in-country logistics and personnel support for the study implementation, which included identifying skilled staff for employment, establishing bank accounts, and learning accounting processes and keeping employment records for paying in-country staff of partner agencies. Further, the non-Haitian staff needed logistics support to identify housing and transportation for various staff while in Haiti for the completion of research-related work; and

3. the identification of existing GBV resources, such as safe-houses, psychosocial support, and advocacy protocols for culturally appropriate and secure referral options for women and girls who might disclose GBV and consent to receive referrals to services.

To achieve the three aims for this trip, the group met with leaders from the Ministries of the Haitian government (e.g., Health, Women’s Affairs, and Social Affairs), administrators and providers at the general hospital that was the proposed site for the research, a centrally-located nursing school, and the University of Haiti to work with faculty and identify research assistants for the study. The research group also met with Haitian NGOs including local and national women’s groups, such as MADRE and Solidarity for Haitian Women. These key stakeholders also provided recommendations to the team for secure housing and transportation for moving throughout the city for future research visits.

Phase three: Seeking GBV solutions

Phase three of the situational analysis occurred three months after phase two, allowing time for the team to review and analyze all the information and data received on the first trip. The third phase was again led by the study principal investigator and five U.S.-based researchers who had extensive experience in participatory research methods, GBV, adolescent health, and working in low-resource post-disaster contexts. The Haitian-American businessman again accompanied the team to facilitate ease of movement, address language challenges, and support collaborations. The aims of the second in-country trip built on the foundational work of the first trip and focused on: 1) holding face-to-face meetings with Haitian-based NGOs and academic institutions to discuss memorandums of understandings between the team members, obtaining office space, securing research-related materials, and completing the ethics review; and 2) convening focus groups with key stakeholders identified in the first trip for discussions about prevention and response to GBV among displaced women and girls in Port-au-Prince. These approaches promoted trust and transparency and facilitated the building of partnerships.

Purpose of focus groups

Key stakeholders included members of women’s groups addressing GBV, health care providers, displaced people–including young community members, and local NGO program leaders. Two groups consisted of women who were currently living in the tent camps. The collective experiences and wisdom of the women provided invaluable insight for the research team into current conditions in the camps, cultural context of GBV, and available resources. A group of NGO program directors and health care providers shared their professional perspectives on current conditions. A group of young adults who were community organizers and leaders offered a unique perspective based on their ongoing work with youth in the camps as well as youth before the earthquake.

Challenges and facilitators of post-earthquake research

Though the trips occurred approximately a year after the January 2010 earthquake, the research team clearly saw that the devastation throughout Port-au-Prince and the surrounding area was severe and rebuilding was proceeding arduously. Large numbers of people remained displaced and the country’s infrastructure was severely damaged. At the same time, some routine had returned to the region as people walking to work and school and street venders actively engaging in their commerce were observed. The massive devastation of the infrastructure and continuing disruption of all facets of Haitian society were challenging to the research team. Team challenges included human subject protection, logistic arrangements, safety, and security. In spite of these barriers and challenges, including the devastation in Port-au-Prince, many facilitators made the project successful. Facilitators came in several forms, most notably in individual Haitian team members, collaborators and informants who showed great strength, dedication, and determination despite their personal and professional obstacles. See Box 1.

Box 1. BARRIERS AND FACILITATORS IN THE HAITI GBV RESEARCH.

Barriers	Facilitators
Logistical support (transportation, communication, housing)	International and local key informants
Cultural differences	International Aid network
Lack of infrastructure	Prior experience in low-resource settings
Safety and Security risks	Haitian collaborators

GBV= Gender-Based Violence

Protection of human subjects

Obtaining approval to conduct the research from a local organization was a difficult hurdle because it was challenging to determine which organization would be most appropriate to review and approve the project. Through key informants, the research team eventually learned of Haiti’s National Bioethics Committee, which was a good fit for the project. The committee reviewed and gave approval for the research. During the team’s many earlier inquiries about ethics approval, the team connected to Université d’Etat d’Haïti (The State University of Haiti) and other professionals with expertise who were potential collaborators.

Logistics

Seemingly simple tasks such as renting a room and communication via phone and e-mail were not simple in the context of post-earthquake Haiti; rooms could be hard to find and telephones and e-mail were unreliable and sometimes not available. Transportation was costly and arduous, partly due to the poor condition of the roads in PAP and the accompanying pace of traffic. Transportation time influenced the choice of a location for an in-country office for the research project, staff housing, and data collection sites. Financial and business challenges included resolving the logistics of paying staff in Haiti, determining the appropriate rate of pay for staff in Haiti, and choosing appropriate incentives for participants. Hiring a Haitian project director and Haitian staff involved many discussions and meetings with local partners.

In post-earthquake Haiti, it was nearly impossible to learn about salary ranges from any of our local informants. The team’s goal was to be fair and compensate staff appropriately without inflating wages that would prohibit successfully completing the project and/or prohibiting future work because of elevated costs. With the large number of international organizations working in Haiti post-earthquake, there was a sharp increase in the number of jobs paid by international organizations; people were naturally seeking to be paid as much as the market would bear. At the same time, the team was cautioned by in country informants that offering wages that were too high could contribute to a country-wide problem of inflation. Through persistence and patience, we were able to get rough estimates of salaries for similar positions, permitting negotiations with staff to be conducted with mutual satisfaction.

Data collection sites were sought that were optimal for the study plan as well as practical. Office space was needed that would provide security for stored data and equipment and a conducive work place for staff. These goals were difficult to reach in a large city with cumbersome traffic, rubble from the earthquake still obstructing some roads, and power outages. The Haitian partners helped the team understand the nuances of traffic, logistics, and locations. Visiting various sites and discussing positive and negative factors for sites helped the team determine the best geographic locations for data collection, the office, and housing for staff.

Connecting with key informants in Haiti

It was necessary to establish partnerships and conduct focus groups with key informants as the research plan was developed. Communication proved challenging during the pre-travel period when mostly-futile attempts were made to set up and confirm appointments for key informants. Communication was taxing while in Haiti as well. No land-line telephone services were operable, which meant that all lists of phone numbers of offices and agencies prior to the earthquake were incorrect. This included contact with individuals, agencies, and organizations. Mobile phones were the only method of communication but numbers changed frequently and did not always work. Availability of electrical power was sporadic city-wide, affecting everyone’s day-to-day personal and professional activities; among other things, Internet connections and e-mail were patchy and unreliable. Facilitators at this juncture came in the form of Haitian and non-Haitian team members who had experience working in Haiti. They encouraged drop-in visits, leaving messages, waiting at the office, and repeating visits in order to meet with the appropriate staff. These strategies ended up being successful in contacting and meeting collaborators.

During the second trip to Haiti, four focus groups were conducted with the goal of hearing different perspectives on the issue of GBV in Haiti historically and currently. The team had planned for four focus groups with participants from the following sectors: Ministries of the Haitian government and health care providers, women survivors who lived in a tent camp, NGO directors, and leaders from the police and justice systems. Due to logistic and system conditions, four focus groups were conducted but with different constellations than originally planned. Groups conducted included NGO and health care providers, youth leaders, and two groups of women survivors. The group of NGO directors and health care providers was limited to three individuals due to miscommunications and limited transportation options. It quickly became apparent, however, that the few who were present gave generously of their time, expertise and insights and were valuable sources of information about the health system with respect to GBV, cultural aspects, current programs and issues. Regarding turnout, we had the opposite experience with the youth group. Two large tables were filled with enthusiastic young people who were neighborhood leaders and teachers. They had a range of education and training, from formal to less formal, and most were not linked to larger organizations. All were eager to explain their hopes and plans for improving the conditions for Haiti’s children and youth. Many were actively engaged in programs that they had self-initiated. For example, in the tent camps, two groups of women gave poignant testimony of their lives, challenges and their ideas for improvement of conditions, both generally and related to GBV.

Safety and security

Safety and security issues were pronounced and pervasive. Pre-study trips of the research team to Haiti were postponed three times due to political unrest and the cholera epidemic that came within a year of the earthquake. An important goal of the trips was to meet with the Haitian partners and key informants, though the team was sensitive to the fact that many of them were overwhelmed by their own difficult circumstances at work and with their families. Trips were postponed to allow more time for Haitian colleagues to recover and have the capacity to invest their attention and time in the research project. Team patience and flexibility with the research timeline facilitated the work.

Discussion

Delivering effective and efficient global humanitarian and development support is highly context specific and requires systematic, prospective and comprehensive situational analysis. Never is this highlighted more effectively than the 2014–2015 Ebola epidemic in West Africa and the timid global response. For example, shipping of inappropriate materials for personal protective equipment resulted in millions of dollars of materials which were unused as they were not relevant to the context. Post-earthquake, the Haitian community experienced a similar lack of effective assessment and understanding of internal and external factors from the global response, ultimately resulting in limited sustainability of programs and resources. Thus, in an effort to prevent GBV in Haiti after the earthquake, the USVI-U.S. research team partnered with multiple local stakeholders and applied the tools of a situational analysis as an initial strategy to better understand the complexity, including strengths of the local context, prior to implementing any program. Research team debriefings as well as self and group reflexivity were powerful and necessity strategies used as challenges were encountered and solutions sought.

Difficulties encountered by the team when conducting the situational analysis, including multiple power outages, limited communication and poor infrastructure for office space and transportation, helped the team better understand the conditions that their Haitian colleagues lived with every day. Empathy and appreciation for their endurance and professionalism grew. The complicated nuances of daily life in Haiti made the research team acutely aware of the heroism of the Haitian partners who showed up for work, discussed the project, provided valuable suggestions regarding revisions, and shared their cultural, logistic, and professional insights. This collaboration with Haitian colleagues provided the research team with essential contacts and details that allowed the project to move forward. This was striking given the facts: all those living in Port-au-Prince experienced great losses of life, homes, and jobs. All were grieving the deaths and serious injuries of close family members, friends, and coworkers. In spite of this ongoing trauma, they showed great strength. Their lives are a testimony to survival and the strong desire to move forward toward improved health as individuals and as a nation. These professional and lay colleagues were generously willing to collaborate with us to improve the lives of women and girls in Haiti. They consistently showed great passion for their country, the people, and improving for the future. The United States and Virgin Island research teams provided resources and research expertise, and the Haitian colleagues and local organizations provided knowledge and expertise of the Haitian context for the situational analysis that allowed the project to move into development and implementation of a GBV prevention and response intervention for displaced women and girls.

In spite of the critical importance of a situational analysis, it has attracted scant attention in the peer reviewed literature and the majority of methodological guidance is found in the grey literature, which includes unpublished reports and evaluations by governmental and non-governmental organizations. As the prevalence of natural disasters increases in the context of global warming and climate change, having a well developed strategy to facilitate expedient delivery of resources and assistance becomes increasingly important. Situational analysis strategies such as described in this manuscript could be promoted to governmental and NGOs.

This report has important strengths. First, it articulates the complex considerations that research teams must consider when approaching a community that has sustained a recent disaster. This point is magnified when the community is one with multiple political, infrastructure, and social challenges prior to the disaster. Second, it is a reflective review of methodological consideration and real world refinement of assessment techniques needed when conducting rigorous research in low-resource settings. In spite of these strengths the study has some limitations. Since Haiti presents a unique context, these findings are not fully generalizable to other populations. Additionally, the number of focus groups gave a more limited perspective than may have been gained with more focus groups. Although the in-country time was intense, it was brief, which may have affected our findings.

The situational analysis was a complex process that taught many lessons including patience and respect for the people and their culture, and patience with environmental conditions. The challenging circumstances encountered by the research team mirror those encountered by others who have done research in adverse conditions.^25,26 Tol and colleagues explored this complexity by looking at mental health and psychosocial support research with 114 participants from Uganda, Nepal and Peru who had been involved in humanitarian settings. One of their findings common to all three countries was the variation in beliefs and understanding that exists among research stakeholders including aid workers, academicians, clinicians, and policymakers. For example, aid workers had a different understanding of research methods from that of the academicians and involved individuals and groups had differing views of the time it should take to conduct the research in these humanitarian settings. This underscores the importance of a situational analysis that incorporates all invested parties.²⁶ Chung and colleagues emphasized that humanitarian crises are by nature dynamic situations that are difficult to manage, both for service delivery and for research, so comprehensive unified flexible approaches are needed for best overall results.²⁵