Very real concerns exist – such as those relating to ethics, physical security, political implications of activities in rapidly changing environments, logistical difficulties and the technical challenges of working with mobile populations and populations with unusual demographic compositions. Yet our experience with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative has demonstrated that, with improved commitment to data collection, evidence-based programming in crisis settings is possible. Although the collection of baseline data requires time and resources, it can help ensure efficiency and success in the longer term as well as provide data for advocacy purposes.
All projects supported by the RAISE Initiative implement a baseline study composed of a facility assessment and a population-based survey. RAISE provides technical support to the projects, ensuring that data collection follows standardised methodology while building the monitoring and evaluation (M&E) capacity of project field staff. To date, RAISE and its partners have implemented facility assessments in five projects in Darfur, the Democratic Republic of Congo (DRC), northern Uganda and South Sudan and population-based surveys in three projects in Darfur and northern Uganda. These experiences illustrate ways in which challenges to collecting data can be overcome in conflict settings.
Appropriate preparation for baseline activities is critical, especially in emergency settings. Before conducting a study, it is imperative to consider the potential direct and indirect effects the process could have on the implementing agency, the beneficiaries and the agency’s ability to continue to work in a given setting.
One of our first steps in planning for baseline studies was to obtain the support of partner organisations’ management. Surveys require significant commitments of finances, human resources and time. RAISE found it essential to ensure that the implementing agencies had a complete understanding of this and fully supported the baseline process before moving forward. This support should include the identification of an individual to coordinate the study from the first day of training to the last day of data collection.
Next, projects obtained approval from the local and national authorities, relevant ethical review boards and local leaders for the proposed study, their support being crucial for smooth implementation. In addition, key stakeholders, such as Ministry of Health (MOH) officials, NGO staff and local leaders, were involved in the early planning and implementation stages. Local leaders proved critical in mobilising community members to participate in study activities. Collaboration with relevant authorities was beneficial across all RAISE settings.
Study tool adaptation
Projects will often be able to adapt existing study tools whose success has already been demonstrated in similar settings, which also allows project staff to compare findings with other similar data. RAISE partners implemented a tool adapted from the Averting Maternal Death and Disability Program (AMDD) Emergency Obstetric Care Facility Assessment, and a survey questionnaire adapted from the Center for Disease Control’s (CDC) Reproductive Health Assessment Toolkit for Conflict Affected Women. Together, these tools provide information on the facility side of reproductive health (RH) services (e.g. equipment, supplies and staffing), the use of services and the current RH status of women served by the project.
Partners then adapted the tools to their local context. Translation is a critical step which is particularly important for survey tools; sufficient time must be allocated for translation, back translation and review. Although this can be a lengthy and complicated process, especially where multiple languages are involved, data team supervisors can be involved early in the baseline process to establish ownership and encourage investment in outcomes.
Sampling is one of the most difficult tasks when conducting surveys in conflict settings. One reason for this is that reliable population numbers are rarely available in such settings. Outbreaks of fighting in Darfur, for example, meant that IDP camp and village populations changed routinely, while in northern Uganda people had begun moving out of camps and into resettlement areas. Frequently, the agency responsible for food distribution possessed the most current numbers but these were reportedly inflated to increase the rations families received. As a result, clarification of numbers of family members as listed on ration cards was very sensitive – and ultimately avoided. RAISE partners worked closely with local leaders to overcome these obstacles. In Darfur, for example, local sheiks in the camps or villages were able to provide RAISE partners with data regarding the number of individuals or families under their leadership.
Recruiting a data collection team
Early identification and recruitment of a strong data collection team are central to study implementation. Data collectors can be recruited from various groups, including local university students, community members and MOH staff. Establishing relationships with members of these groups may lead to secondary programme benefits. For example, RAISE facility assessment data collection teams included NGO and MOH staff, thereby contributing to an improved collaboration with the local MOH. However, during the population-based survey, the involvement of MOH staff introduced new challenges where the local population mistrusted the government and would probably have refused to participate in the survey if MOH staff had been involved in data collection. In such cases, MOH officials were asked to participate in alternative tasks, such as data entry and analysis.
There are a number of other considerations in the selection of a data collection team. In some countries, ethnic and political sensitivities restricted the ability of some to travel or affected respondents’ willingness to be interviewed. Varying language proficiencies, where multiple languages and dialects are spoken, led to new challenges. Literacy skills were challenging to assess, especially in places where languages or dialects are rarely written. Education levels impacted the time needed to complete training activities. Data collection required a significant time commitment; it is important to ensure that all team members understand the time demands when they agree to participate.
Training to increase local capacity
Data collection teams were trained by RAISE partners, with technical assistance from RAISE staff. Training of data collection teams lasted three to four days for facility assessments and seven to ten days for population-based surveys. Flexibility in the time allocated for training was necessary to allow for variations in the groups’ starting knowledge and skills.
RAISE developed the trainings with partners to ensure good quality data and to build the capacity of partners and the individuals involved (see case study below). As much as possible, project staff and supervisors led the planning, facilitation and training activities. This level of involvement resulted in stronger knowledge and confidence in the tools, improved leadership and increased quality of supervision and data collection. RAISE provided ongoing technical support throughout the process, such as standard presentations that could be adapted for trainings, making leadership by field staff a less daunting prospect.
It is important that implementation of baseline assessments adheres to the approved methodology even in turbulent circumstances. Once samples are selected, survey implementation may be affected by rapidly changing security and road conditions. One RAISE survey team in Darfur had to suspend data collection because of fighting near the survey area that cut off access to the target population but resumed collection when the area became safe again. In northern Uganda, a number of villages which had been selected for the RAISE sample became inaccessible due to rain; teams modified transportation options when possible and, in rare cases, selected additional clusters.
During any study, but especially in insecure environments, it is essential to consider the safety and security of the data collection team and respondents. Good training provides data collection teams with guidance on how to respond to unexpected or potentially dangerous events. In addition, teams should have adequate means of communication and transportation in case of an emergency and should obey local travel restrictions. Establishing good relationships with local leaders and informing them when data collection will occur are integral to ensuring safety and security. During the RAISE surveys, local leaders provided up-to-date information about security and facilitated communication and transport. Regarding the safety of respondents, confidentiality and privacy must be strictly maintained by all involved in study activities. This was emphasised throughout training and implementation. In northern Uganda, the survey included questions about the respondents’ experiences with gender-based violence. The RAISE survey team established a protocol of referral for counselling, which each interviewer practised prior to beginning interviews.
Data entry, cleaning and analysis
To make the data most useful to those who work in the field, RAISE supported field partners with training to enter, clean and analyse the data. This training gave local staff the opportunity to develop their analytical skills which they were then able to apply to the analysis of routine monitoring or other study data. In some areas, data entry presented challenges due to lack of local capacity. Individuals with computer skills were often not available for short-term work for a variety of reasons. Some projects partnered with MOH or university staff for data entry. RAISE provided standardised databases adapted for each project.
Local capacity for data analysis often tends to be quite low, so RAISE organised workshops with partner agency staff on analysing the data, using the findings for programme improvement and advocacy and planning for data dissemination. Field staff learned new skills in extracting useful information from the database.
Case study: northern Uganda
During the implementation of the population-based survey in northern Uganda, more than 1,400 women were interviewed in six areas, including IDP camps, rural villages and urban populations. Previous survey experience indicated that varying resettlement rates in each IDP area, combined with the onset of the harvesting season, would affect response rates and the ability to identify respondents. During site visits prior to the survey, the RAISE team was repeatedly told that women would not be at home either because they were living part-time in adjacent resettlement areas or worked in the fields during the day.
Training therefore required flexibility on the part of the interviewing team, and the ability of supervisors to meet the challenges of empty households, dual residences, women in the fields and low response rates. Rather than following the traditional methodology of dividing the tasks of interviewers and ‘locators’ (who identify houses and select participants in accordance with the protocol), flexibility was maximised by training the strongest members of the team in both skills. This proved to be tremendously valuable, as supervisors could decide the most efficient division of tasks according to the given circumstances.
For example, when a team learned that women were home only in the afternoons, 15 individuals could be divided so that 10 people identified women for interviews early in the morning. Those remaining stayed in the central location to interview the few women arriving in the morning. The 10 locators could identify up to 50 women from surrounding clusters, and then shift back to interviewing in the afternoon to accommodate the influx of women later in the day. This system allowed the team to be responsive to each situation (including notifying women up to two days before the interview would be needed) and ensured that human resources were not underutilised.
Those who had been trained in both interviewing and locating reported that it had been more rewarding. As one interviewer/locator noted, “it was interesting and better to know more than one skill so that we could have variety in our job.”
The combination of increased competence on the part of supervisors and varied skills among data collection teams gave them the flexibility needed to respond to the majority of challenges which arose. Ultimately, the teams achieved a response rate in excess of 85% in areas where previous surveys had reported less than 70%. Such flexibility is an asset to successful survey completion, as these scenarios are common in any survey and even more so in conflict situations.
Evidence-based programmes are essential to the provision of good quality RH services in humanitarian emergencies, and our experience with the RAISE Initiative has shown that collection and use of data in unstable settings – though challenging – is not impossible. The recent implementation of successful baseline studies by RAISE highlights the importance of:
- building the capacity of field staff to take on leadership roles in data collection
- flexibility in responding to changing situations
- involving stakeholders, in particular government and local leaders, at multiple stages
- building local staff skills in data analysis and use.
These elements ensure good data collection in any setting but are especially important in areas of conflict and instability.
Reproductive Health (RH) in Emergencies Conference 2008
Kampala, Uganda : 18-20 June 2008
Organised by the RAISE Initiative, in collaboration with the RHRC Consortium, this conference will bring together a wide range of actors from the fields of RH in emergencies, reproductive health, humanitarian assistance and development to contribute to the expansion of comprehensive RH services in crisis settings.
Please visit www.RHinEmergenciesConference.org/2008 for further details. Abstracts are being accepted online now through to 31 January 2008.
 For example, the ratio of men to women may be different as men may be away fighting or have been killed.
 This tool will shortly be made available on the RAISE Initiative web site.