Six major themes emerged from the interview and written responses: Respectful Relationships; Increased Knowledge and Experience of Research; Participation at all Stages of Research; Contribution to Public Health Action; Support and Sustain Research Opportunities; and Managing Challenges of Research Capacity Strengthening. These themes were common to both Solomon Islander and Australian respondents.
Respectful relationships between research workshop facilitators, participants and East Kwaio community members were reported as pivotal to the success and sustainability of RCS activities. Research activities reportedly improved the often antagonistic relationship between AAH staff and the East Kwaio community, particularly people from the nearby mountain areas who have chosen not to convert to the introduced Christian religion and continue to practice ancestral religion. AAH staff are reportedly more respected by the East Kwaio community as a result of the workshop. One Atoifi researcher stated the RCS activities have “created a good relationship between surrounding community and Atoifi hospital compared to our previous relationship with both the coastal and mountain community.” Another Atoifi researcher reported “Research is part and parcel of valuing things, people, community, public and being committed in doing the best for people through working together with them. We want to work very closely with mountain people to provide health services for them, as this will be an unique model which can’t be seen anywhere in the Solomons”.
The reputation of AAH was perceived as being improved beyond the immediate community. RCS activities “gives recognition to the hospital by the outside research institution like Solomon Islands Medical Training and Research Institute, Ministry of Health and JCU”, stated an Atoifi researcher. One Australian researcher stated, “There has to be an increase in reputation of Atoifi as a research place for doing research. The powerful bits about this project are that we are working with people that are incredibly influential in their community … they have influence in the area and also nationally”.
Valuing community leaders as partners in research was identified as important for researchers from both Atoifi and Australia. For some this was a new way of working. One Australian (laboratory based) researcher stated, “The approach is different to anything I have considered- I would not have considered people outside the scientific community and would have relied on local medicos- but community people are really interested in being part of the process.” He went on to say, “I thought it would be a mess but was proven wrong to my original assumptions. With local people we achieved more than I would have ever considered possible.” An East Kwaio chief stated of his appreciation of chiefs and community members being involved.
“Hem mekim heart blo mi hem feel gud. Why mi feel gud, bikos, iumi involvem not only olgeta man save lo raetim, but disfela wokshop, samting mi hapi long hem nau, no mata man hem no raet, but, hemi putim tingting blong hem for iumi share together”.
Translation: It makes my heart feel good. Why I feel good, because, we involved not only the people who have knowledge to write, but this workshop, the thing I am happy with it, even if someone can’t write, but they could contribute their knowledge for us to share together.
Relationships between many of the Solomon Islander and Australian researchers have been ongoing for two decades (EK, HH, TRH, RA, DM & MRM) [19, 20, 37, 38]. The respectful, sustained nature of these relationships has been critical to the research strengthening process. Respectful, mutual relationships were also important to the Australian researchers, as stated by one visiting Atoifi for the first time: “Relationships were built in process- because we included people – not using an authoritarian outlook- we included people and mentored that is why we have built trusted relationships”.
Increased knowledge and experience of research process
Knowledge and experience of public health research processes were identified as key outcomes of the RCS activities. A number of researchers discussed the movement from theoretical to practical health research knowledge. “Theory about research has become a reality as I practically apply what I have learnt in real practice. This has helped me to understand the meaning of the research terminologies and understand the whole process i.e. research hypothesis / question, various ways of data collection and analysis as well as compiling and reporting results,” said one Atoifi researcher. An Australian (qualitative) researcher discussed the broadened understanding of research resulting from the workshop. “I have learned more about research - my espoused methodology, the qualitative methods I employ for undertaking community based research and a whole new world of quantitative methods”. Another Australian researcher reported, “It (the workshop) has allowed me to have a greater understanding of the research process because it needed to be distilled into simple language to be accessible to all participants but still retain its research rigour”.
Increased knowledge and experience of specific techniques used in qualitative research such as transcription of a face to face interview recording was identified by one chief with vast experience as an orator, community mediator and interviewer.
“We don’t know, hau bai iumi go about the process ia; taim mifala go… stori no moa; Iu laik repeatim olsem samting; iu laik long olsem, ah, lelebet part iu laik English moa long em; lelebet part iu laik language moa long em; lelebet part iu laik Pijin moa; and repeatim and repeatim; but mifala no save`, but taim word to word iu barava raetim samting ia…Man, ten minute interview or, twelve minute interview, iumi raetim about three hours. So datwan, man, hem wanfala samting wea mi barava learnem during long research workshop”.
Translation: We don’t know how to go about the process (of research); when we interviewed we repeated something, spoke a little in English, a little in Pijin, a little in language (East Kwaio), but when we wrote it word for word, man, a ten minute interview, or twelve minute interview you write (transcribe) for about three hours. So that, man, is something I really learnt during the workshop.
More confidence to undertake community based public health research was identified as an outcome of the workshop by researchers from both Solomon Islands and Australia. “Why I can do research at any time is because of the confidence I gained after the workshop research experience in April,” stated an Atoifi researcher. Another Atoifi colleague reported, “I will start to look at priority areas that will need research and start with small projects. Firstly the small projects should give me enough confidence to start looking at major research projects”. For Australian researchers, confidence to undertake research grew from being exposed to new people and new opportunities. One Australian reported, “Testing out my capacity to be able to research in a team where I haven’t known anyone and build relationships two-ways in a short space of time in a respectful way. I have learnt, been able to go the journey with that and been enriched.” Another Australian reported “I have learnt about the potential for change if we just act together- no need to keep it tight and controlled- go with it using values as a basis for decision-making. If the community want it and we can contribute- let’s go”.
The workshop elicited interest from nurses working in the hospital. “A male registered nurse… was looking for a research book to further read on what was presented” reported an Atoifi researcher. Nursing students were reported to be seeking involvement in research projects. “A student asked for off day because she wants to go out and be involved in collecting data at the community as part of their practice and further asked for (a day) off on Thursday the second week to listen to the presentation, (it) is amazing”, a Atoifi researcher reported. The researcher went on to explain that the knowledge and experience gained through the activities, “will help me to teach others”.
An increased understanding of the ethics of community based public health research was highlighted by researchers from both Atoifi and Australia. One Atoifi researcher stated, “I must follow and abide by the ethics of research so that no negatives will interfere with the research process.” For one Australian (laboratory based) researcher this was highlighted through the ethical consideration of respecting local cultural rules that meant faecal samples were not to be taken to Australia. The researcher stated, “I would like to have taken samples back (to Australia) - I need to have value added”. The “value” referred to was from the perspective of adding protozoal prevalence studies to the faecal samples in an Australian laboratory.
Participation at all stages in research
Taking part in all stages of the research process was identified as important. One Atoifi researcher stated, “actually taking part in the process or the stages that begins in drafting of proposal which involves consultation with the administration for consents/communities and individual …gives me the confidence to become motivated to undertake research”. One Australian researcher reported, “Some apparent challenges or difficulties were able to be overcome through leaders at the hospital and community participating in the workshop and that community leaders were able to assist in formulating the research question and methodologies – for example this was able to overcome some social and gender sensitivities around the collection and microscopy of human faeces for the gutworm study”.
All respondents discussed the importance of the partnership with chiefs and community leaders, with one Australian stating the chiefs and community leaders’ participation had changed the way he thought about engaging participants in research.
“When we talked with (the chiefs) – if we had simply not had that talk, we wouldn’t have learnt anything about this (culturally-appropriate approaches to research). We would have thought local people were being difficult- it is a case of asking. As Daniel Borston said “the greatest obstacle is not ignorance of knowledge but the illusion of knowledge.” I would have planned with medicos I now know that if I do more research I will have the support of the people in the mountains. I would have gone in with colonial assumptions; I didn’t understand they were assumptions. I did a lot of learning about assumptions”.
Another Australian researchers stated that the chiefs, “talked through the things they know about TB and which ones they would do (in the pilot study)…they chose TB in the mountains…it highlighted community feeling they owned it”.
One East Kwaio chief reported how health research was typically not done in partnership with the people from Solomon Islands. “Most of time, people think, research, hemi blong olketa white man, ol no save doem ia. …hem no fitim mifala olketa local man.” Translation: Most of the time people think research belongs to the white men- they don’t know how to do it …its not something for us locals. He added,
“Mifela man no save read na raet…but still we got the wisdom, to share. So dat wan nao hem wanfala samting wei mi barava hapi long hem. Wei disfala workshop mi hapi long hem, nau dis wan, hem no wansait no moa, but everiwan, iumi insait long disfala research. And datwan hem makim mi barava hapi tumus”.
Translation: We (chiefs and community leaders from East Kwaio mountains) can’t read and write, but we still have wisdom to share. So that is one thing that makes me really happy. What I am happy about regarding this workshop is that it wasn’t just one group – but everyone - we were all included in the research. That makes me very happy.
Involvement of community chiefs and leaders ensured community participation in pilot research projects. An Atoifi researcher reported, “This workshop opens the community’s mind to accept research work in their villages and not resisting it as before, because they have some knowledge about research”. An Australian researcher revealed his surprise at “the phenomenal response to requests for specimens that we achieved in the time we were here”, demonstrating the willingness of community members to be involved.
Contribution to public health action
The involvement of outside researchers, local health professionals and community members led to immediate public health action and wider influence on national public health policy. This was highlighted through three examples:
Antehelmintic treatments for individuals and a whole village (Na’au, East Kwaio).
All people who had parasitic worm eggs identified in their faeces were offered anthelmintic treatment within 1 week. Since one of the study communities (Na’au) had a high prevalence of hookworm, AAH staff worked with the community and treated all residents using a mass drug administration with albendazole. One Atoifi researcher reported the experience of a chief who had participated in the pilot study.
“I was also approached by two villagers from Na’au, expressing how Albendazole relieved their long existing abdominal pain. They were complaining of this abdominal pain for almost over 10 years and was diagnosed of having peptic ulcer at the hospital, however after taking Albendazol during the de-worming process at Na’au it relieved their abdominal pain, this is a miracle to them and they were telling people about this experience”.
Village leaders led a community project to increase cleanliness including keeping pigs in designated areas and digging drains in low lying areas of the village. Within two weeks results from the parasite survey were included in an application led by community leaders to improve sanitation. “Benefits were also the practical outcomes that have arisen because of the workshop… (it has) accelerated and provided supporting evidence for a sanitation project in the village”
Screening for Lymphatic Filariasis of a whole village (Alasi, East Kwaio)
During the workshop, a male community member presented at Atoifi Hospital with elephantiasis, a clinical manifestation of lymphatic filariasis (LF). A survey was designed with input from Solomon Islander researchers and community members supported by the Australian researchers (primarily RS). Local ethics approval was obtained and an entire village survey conducted during one night (between 10 pm and 2 am) only one week after the clinical presentation. Samples were split with one set of blood slides screened at Atoifi laboratory and another sent to JCU (Australia) for antigen and antibody testing not available at Atoifi.
“I was very impressed at the speed, skill and organisational ability of the Atoifi team to respond to the case by discussing the appropriate blood survey for lymphatic filariasis with LF experts in our team, engaging with community leaders to arrange the bleeding of the entire village in the middle of the night, training in appropriate technical aspects of collection, storage and transport of specimens and implementation of the whole study in a matter of days after the patient presented at the hospital”. (Australian researcher)
The survey showed that LF transmission was not occurring in Alasi (manuscript in preparation). The results were reported back to the villagers in Alasi, with a now reduced anxiety about the likelihood of others developing elephantiasis as a result of LF. The result was also communicated to the Ministry of Health and assisted Solomon Islands to be granted LF-free status by WHO later in 2011.
Contribution to national health policy.
The RCS activities were also reported to be influencing other national and international health research agendas, despite the remote location of Atoifi and the limited resources. One Atoifi researcher reported the impact the TB pilot study had on the national research agenda.
“One successful story was the presentation of the TB survey at the National level by PHC (Public Health Co-ordinator) a few weeks ago…he was then interviewed and put to media. Now the National TB for the country are moving in to support the research project that have been started by Atoifi/JCU Team. (It has) resulted in everybody asking to know more about this research approach done by Atoifi and JCU”
Support and sustain research opportunities
A number of new and expanded research activities at Atoifi were identified through the RCS activities, including expansion of TB, LF and intestinal worms research in East Kwaio (in both coastal and mountain regions) and support for non-communicable disease research such as studies on diabetes, tobacco and marijuana use. A number of village leaders in East Kwaio have expressed a strong desire to be involved in further studies in these areas.
The need to strengthen skills to support these opportunities including to report and publish research results was strongly identified. An Atoifi researcher explained, “It’s the editing report writing that I see become the hiccough (sic) for me as this will give me the sense of achievement after all instead of having this negative thought of being not able to complete my own project. What I started I have the responsibility to complete”.
The workshop was reported to have assisted the development of reporting skills for one Atoifi researcher.
“I have been working on a mini research project trying to understand what the textbook is saying when JCU came along to run the research workshop. All the questions I have been asking myself throughout the process have been cleared and answered during the two weeks training. As a result, I was able to complete the process of my mini-research project with a clear understanding on how I have done it. And this research will be presented at the 3rd biannual PSRH conference in Honiara on July 5–8, 2011. This will be my first step ever in presenting a research paper and I count it as a first-step in my professional development”.
An Australian researcher reported concern about sustaining ongoing research capacity building activities to enable improved health. “The danger of present project is that it will not make changes to health services, (we) need to do further work to trial and make changes. It’s important the next steps are linked to health impact possibilities to improve health”.
RCS undertaken at Atoifi, rather than having to leave the campus or the country, was identified as a benefit to both individual researchers and the institution. It allowed for strengthening of research knowledge and experience with a broad range of professional and community participants in the local context and using local examples. This allowed RCS while maintaining the operations of the hospital and college of nursing. It also encouraged researchers from Atoifi and Australia to consider postgraduate and other formal study. One Atoifi researcher said the workshop “encourages me to do my PhD study in public health area”. An Australian researcher discussed her plans to report learning from research capacity work in her PhD. Another Australian researcher expressed “It would be wonderful to see ongoing exchanges of staff between Solomon Islands and Australia – both for formal training and short term exchanges”.
Managing challenges of research capacity strengthening
A number of challenges were identified throughout the workshop that required considered management. Understanding English was a challenge for some community leaders, most often during the formal presentations. Some JCU researchers gave presentations in Pijin (DM & MRM) but some presentations were given in simple English and periodically translated (or further explained) in Pijin by HH or Kwaio language by EK. This was not satisfactory, as reported by one chief.
“Taim olketa man blong iumi, long bush olketa kam down na participate, laik, Professor hem tok English. Taim hem tok English, for hem kam lo olgeta man e read na write, hem gud. But mifala man no save even English, but mifala no save, datwan hem barava olsem, hem barava, hem no gud long mifala”.
Translation: When our people from the bush came down to participate, like, the Professor spoke English. When he spoke English, for those who read and write, that is good. But for us who don’t know English, we don’t understand, that is very, like, its really not good for us.
Australian researchers agreed. One stated, “I wished we could have had more Pijin/Kwaio used in the workshops as I am sure some of it was lost on the community participants, because they told me.” Another reported, “Language: when requesting feedback (via written One Minute Reflections exercises at the end of each session) we got asked really good research skills questions on some stuff we had spoken about, that we had said quite clearly in English. That was a negative”.
Challenges to undertaking RCS were different depending upon the researchers’ country of origin and level of research experience. For Atoifi researchers challenges lay in the logistics of organising the workshop and how to encourage active participation in RCS activities while continuing to operate the Hospital and College of Nursing. One Atoifi researcher demonstrated this struggle, “Nurses expressed their disappointment because they could hardly attend the research workshop - (it) is a clear indication of how they value this capacity building research workshop”. The negatives for Australian researchers related to working in a less-resourced environment, including lack of electricity, printing, internet and other communication and health risks (malaria, gastroenteritis). However, the negatives were not insurmountable. One Australian identified ways forward, despite the challenge of limited infrastructure at Atoifi.
“Negatives include the difficulties in transport and communication – there is a lot of interaction and planning and follow up before and after the workshop. This is difficult when the internet and phone/fax are not working and there is only intermittent electricity. This makes collaborative writing of articles/manuscripts challenging and increases the amount of time required to finalise report writing – however reporting back to community through community forums at the village level does not face such issues and so results can get back quickly”.
The social expectations of having to perform duties as a senior researcher or ‘big man’ in the Solomon Islands and having many people in work and living spaces were also identified as challenges.