Human Research Ethics Committees (HRECs) ensure ethical measures are in place, and maintain the scientific quality of research involving human participants (Gelling, 1990). In order to fulfil these obligations, HRECs review all the aspects of the research, including the recruitment of humans as study participants. This is to ensure that the research protocol meets the stringent condition of all participants being recruited voluntarily.
The recruitment of study participants is a significant element in the research process, it is therefore one of the key areas for HRECs, as was the case in my (still ongoing) PhD research at the University of Newcastle, Australia. The purpose of my research was to explore the relationship between Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy (AYUSH) integration processes, AYUSH doctors’ practices and the goals of Indian primary healthcare centres and the health system. The HREC at my university approved my study on the basis that it involved voluntary participation and informed decision of participants. Following standard processes and templates, I developed a three-page long and detailed participant information statement to send to potential participants, giving them two weeks to decide whether to participate or not. However, while implementing ethical research principles in the real-world context, I encountered certain issues at the early phase of my data collection, which directly affected potential participants’ decisions on whether or not to participate in the research. For instance, the medical hierarchy embedded in the Indian health system was a major underlying factor, which I will discuss more in detail in the following section.
I had spent ten months for my PhD data collection in an eastern Indian province where I was observing primary healthcare centres and interviewing different health systems actors such as AYUSH doctors, bio-medicine doctors, nurses, pharmacists and health system administrators at different levels of administration. I encountered a few instances when nurses and pharmacists were concerned about their participation and often wondered whether the bio-medicine doctor or superintendent had participated in the research. Reflecting upon this, I found out that if a senior Medical Officer or the superintendent (also) participated in the study, this information could influence the junior medical officers, AYUSH doctors, pharmacists and nurses’ decisions to become participants because they would then feel obliged to do so. I therefore adopted various strategies to counter this influence of medical hierarchy on my recruitment process. I have described them in the following sections.
Keeping the participants’ identity confidential
Following the HREC’s ethics protocol, I did not reveal who had or hadn’t participated in the study to any of the participants, even when asked. Additionally, I explained the importance of confidentiality to participants, emphasising that I would also protect their identifiable information, once they participated in the research. Moreover, I went through the participant information statement again, reiterating the voluntary nature of participation and the fact that participants had the right to stop the interview at any point in time. Throughout this research process, I could recruit participants for my study while maintaining the ethical norm of confidentiality.
Another strategy for maintaining confidentiality was interviewing participants in different settings, on different days. During data collection, there were occasions where more than one participant from the same health centre expressed an interest in taking part in the study. In such cases, I deliberately scheduled the interviews with a minimum of ten days interval, based on the interviewees’ availabilities. Furthermore, I requested that the participant be interviewed at their respective office room at a post-duty time to maintain confidentiality.
Managing hierarchy in the health system
The embeddedness of hierarchy (Varghese et al., 2018) and its significance in health system functions, is evident in the Indian health system, therefore the possibility of hierarchy affecting my research process cannot be ignored. With this in mind, I adopted a bottom-up approach to the participant recruitment process, and interviewed junior level health system actors first before proceeding to seniors and health system administrators. This particular strategy was adopted whenever I interviewed more than one people in a single health centre or institution.
These strategies enabled me to address emerging field level ethical challenges and continue my data collection process.
In sum, I conclude field-level difficulties can always emerge in health policy and systems research due to entrenched power relations that are structural to health systems. It is impossible for HRECs to identify all the potential challenges that can arise during the execution of the research. Therefore, it is vital that researchers practice reflexivity throughout the research process and make it a central principle of their research journey. Keeping the principles and processes of research ethics as a primary focus to identify and address emerging ethical issues at field sites is crucial to identifying and managing challenges that will arise in HPSR.