Research workshop to research work: initial steps in establishing health research systems on Malaita, Solomon Islands

Introduction Atoifi Adventist Hospital is a 90 bed general hospital in East Kwaio, Malaita, Solomon Islands providing services to the population of subsistence villagers of the region. Health professionals at the hospital and attached College of Nursing have considerable human capacity and willingness to undertake health research. However they are constrained by limited research experience, training opportunities, research systems, physical infrastructure and access to resources. This brief commentary describes an 'Introduction to Health Research' workshop delivered at Atoifi Adventist Hospital in September 2009 and efforts to move from 'research workshop' to 'research work'. The Approach Using a participatory-action research approach underpinned by decolonising methodologies, staff from Atoifi Adventist Hospital and James Cook University (Queensland, Australia) collaboratively designed, implemented and evaluated a health research workshop. Basic health research principles and methods were presented using active learning methodologies. Following the workshop, Atoifi Adventist Hospital and Atoifi College of Nursing staff, other professionals and community members reported an increased awareness and understanding of health research. The formation of a local Research Committee, improved ethics review procedures and the identification of local research mentors followed the week long workshop. The workshop has acted as a catalyst for research activity, increasing structural and human resource capacity for local health professionals and community leaders to engage in research. Discussion and Conclusions Participants from a variety of educational backgrounds participated in, and received benefit from, a responsive, culturally and linguistically accessible health research workshop. Improving health research systems at a remote hospital and aligning these with local and national research agendas is establishing a base to strengthen public health research and practice on Malaita, Solomon Islands.


Introduction
Health research in a majority world nation such as Solomon Islands is very challenging [1]. In Solomon Islands, resource and system constraints limit opportunities to plan or undertake health research. Internationally, health researchers have been challenged to close the 'know-do' gap [2]and undertake research that improves health outcomes [3]. Here we report on a health research workshop conducted at a remote hospital in Solomon Islands to enhance local health research capacity. We also report on how lessons from the research workshop are informing future research.
Solomon Islands is an archipelago Pacific Island country of 595 000 people speaking over 70 languages [4,5] Over 80% of Solomon Islanders live a subsistence lifestyle in village settings and the country is ranked 135/ 182 on the UNDP Human Development Index [6]. Solomon Islands is re-establishing governance and civil systems following the breakdown of law and order from 1998 to 2003 [7]. Public health priorities for Solomon Islands include rural water supply, improving health centres and addressing tuberculosis, malaria, HIV/AIDS and sexually transmitted infections and common childhood diseases [8].
Atoifi Adventist Hospital (AAH) is the largest nongovernment hospital in Solomon Islands. It is a 90 bed general hospital located in remote East Kwaio, Malaita Province. The hospital can be accessed by light aircraft, trading ship, motorised canoe and by foot. There is no road access. Most hospital employees live on the hospital campus including two Medical Officers and 27 Registered Nurses. Atoifi College of Nursing (ACON) is located on the AAH campus. ACON delivers a three year Diploma of Nursing to 60 students from across Solomon Islands and other Pacific Island countries. The hospital is located near the coast at Uru Harbour on the eastern side of the island of Malaita.
The hospital is located in an area of great ethic and religious diversity. Most people in the immediate coastal area live in large villages of up to 500 people and belong to one of five major Christian denominations. People in the nearby mountains live in small family hamlets and practice Ancestral religion. Many of people who practice Ancestral religion are unable to access hospital services because the entire hospital building is culturally taboo due to the maternity ward being located within the hospital building. This means it is not possible to enter the hospital without serious social, spiritual and cultural consequences requiring compensation to the ancestral spirits. After managing the medical laboratory at AAH 1992-1994, DM subsequently (2000 -2006) used a participatory action research approach to collaboratively investigate barriers to health care at AAH and collective approaches to provide culturally appropriate health care for people who practice Ancestral religion. During this period enduring personal and professional relationships were established with many AAH employees and community leaders [9][10][11][12].
In September 2008, DM arranged for AAH Director of Nursing, AAH Mental Health Nurse and EK (a community chief) to travel to Cairns, Australia to deliver a presentation on incorporating spiritual paradigms into mental health services at AAH, from both an institutional and community perspective. While in Cairns these men met with DM and AC and discussed ways to build on collaborative health research opportunities and strengthen health research systems at AAH/ACON. Given leaders from AAH and ACON contribute to numerous professional associations and boards and make significant contributions to local, provincial and national health care delivery and policy forums, AAH and ACON are well positioned to contribute to local and national health research in Solomon Islands. An 'Introduction to Health Research' workshop was proposed and ultimately delivered at AAH/ACON in September 2009 following a formal invitation to JCU health researchers by AAH chief medical officer. This brief commentary outlines the workshop and describes initial steps taken to establish and strengthen health research systems at this remote hospital.

The Approach
The Workshop In September 2009, a five day health research workshop was held at AAH involving 102 medical professionals, auxiliary staff, nursing students, local school teachers, chiefs and community leaders. Action research approaches underpinned by decolonising research methodologies informed the design and implementation of the workshop, including monitoring and evaluation processes [13,14]. Sessions were facilitated by three public health researchers from James Cook University; (AC, DM, MRM) two of whom (DM, MRM) had worked or conducted research at AAH previously, spoke Solomon Islands Pijin and had long-term relationships with many workshop participants.
Morning and evening sessions were facilitated each day. Sessions covered the same content but were facilitated in different locations on the AAH/ACON campus and used different languages. This allowed participants to choose the time, location and language of delivery and ensure equitable and culturally safe access for workshop participants. Two hour evening sessions were facilitated in the AAH chapel, used English and were primarily attended by nursing students, hospital staff and auxiliary workers. Two-hour morning sessions were facilitated in an ACON classroom and predominantly used Solomon Islands Pijin. Morning sessions were primarily attended by chiefs and community leaders. Some chiefs and community leaders from Christian villages were unable to attend the evening sessions because the use of English or the logistical challenge of travelling at night. Other chiefs, who practice Ancestral religion, were unable to enter the hospital building because of cultural taboos associated with entering a building used for childbirth [12]. Facilitating the workshop in two parallel sessions allowed participation from a variety of social, religious and professional backgrounds and ensured effective communication in a culturally safe location. Active learning methodologies were employed to allow participants to consider new ideas and try them out [15]. This was enacted by creating spaces for individual exercises and reflection, discussions in pairs and small group activities.
The workshop included: i) an overview of health research, ii) finding a research topic, iii) quantitative and qualitative research methods, and iv) writing and reporting research results. Research planning, methods and reporting were discussed using examples from facilitators' previous research in Solomon Islands and Australia. That research is underpinned by the 'worldview' of the researcher was explored. Other topics explored included: defining a research problem; conducting structured and semi-structured interviews; focus group discussion techniques. Participants engaged in practical exercises where qualitative data was collected, coded, analysed and discussed in groups.
Blank research proposal outlines were distributed at the beginning of the workshop with interested participants supported to develop brief research proposals as the workshop progressed. Research interests reflected the eclectic range of participants: TB treatment, neonatal cord infections, HIV/AIDS prevention, oral thrush in children, respiratory infections, ethics processes, postoperation abscesses, reading skills in school children, nursing student participation in chapel, student absenteeism and hospital electricity demands.

Monitoring and Evaluation
Monitoring and evaluation occurred throughout the workshop. At the completion of each session participants were invited to write a One Minute Reflection [16] on two questions: (i) What was the most useful, meaningful or intriguing thing you learned during this session? (ii) What question(s) remain uppermost in your mind as we end this session?
Responses were discussed between AAH/ACON workshop co-ordinators and JCU facilitators following each session. A verbal summary of One Minute Reflections was returned, discussed and elaborated on at the beginning of subsequent workshop sessions. Sessions were adapted to respond to One Minute Reflection replies. Between 56-89% of workshop participants completed One Minute Reflections. Responses were written in both English and Solomon Islands Pijin. At the completion of the workshop MRM summarised the 342 One Minute Reflection responses. DM, RA, HH and EK further reviewed and refined summaries with MRM (Table 1).
On the final day of the workshop participants were asked to evaluate the content and process of the week long workshop in one of seven focus group discussions. Senior AAH/ACON staff and a chief facilitated the focus group discussions to consider: (a) What was successful about the workshop (content and process)?; (b) What could have been done differently to improve it (content and process)?; (c) What is the most significant change that has occurred for you since participating?; (d) Do you feel more confident to undertake research since participating? Why? Participant responses are summarised in Figure 1: Focus Group Discussion Participant Responses.
Seven weeks after the workshop MRM returned to AAH to collaboratively review monitoring and evaluation results with senior AAH/ACON staff and a chief, feedback workshop evaluation to workshop participants and collaboratively write the workshop report and draft publications. MRM, RA, HH and EK used Appreciative Inquiry methodology [17] to reflect upon the experience of the one-week workshop using a strengths approach and to build energy and research capacity for future research. Four questions were considered: 1. What 'gave life to the workshop? 2. What 'could have been'? 3. What 'should be'? 4. What is needed to 'sustain change'? Responses were collated and are summarised in Table 2: Appreciative Inquiry Reflection on Research Workshop.

Immediate Impact of Workshop
"Now research has bring me into curiosity" -(Workshop Participant) The immediate impacts of the workshop (including emerging questions) were reported by participants in One Minute Reflections. One participant stated it was "good to know the basics of research" and it was "very clear and simple", however "I'd like to know more about how to analyse data." Practical exercises stimulated further questions: "I now appreciate interviewing and developing themes with the person/people interviewed" but "Can I make reactions while (asking) probing questions?" Focus group discussion participants reported an increase in knowledge about health research: "Workshop participants do acquire basic knowledge about research and now able to do research synopsis. Generally the participants are happy and satisfied. This is because (a) use of simple language e.g. English to Pijin, (b) facilitators interacts more with participants." Participants also reported a growing confidence to undertake research activities and motivation for further education: "Me garem confidence for helpem community blo me for undertandim importance blo research" (I have confidence to help my community understand the importance of research); "Help to give confidence to do research and motivate us for further studies."

Ongoing Impact
In the week following the workshop a seven member research committee was established at AAH. Members of the committee include health professionals, a community high school principal and a community chief. The research committee plans to co-ordinate research activities at AAH/ACON and provide leadership for emerging local researchers. Research systems are also being strengthened at AAH through the enhancement of research ethics committee documentation and procedures. In February 2010 a proposal for a collaborative JCU-AAH HIV prevention study was submitted to a major funding body. In March 2010 three senior AAH/ ACON staff were appointed to adjunct positions at the School of Public Health, Tropical Medicine and Rehabilitation Sciences at James Cook University. Two of these (RA and HH) travelled to Cairns, Australia in September 2010 to present the process and outcomes of the research workshop with MRM at the 2010 Fulbright Symposium [18]. This led to a further application for funding for a collaborative project to investigate a number of Neglected Tropical Diseases at AAH and surrounding communities.

Discussion and Conclusions
Participants' eagerness to actively engage in the workshop conducted in a location where there are few educational opportunities encouraged a positive learning environment for participants from a range of social, cultural, religious and professional backgrounds. The preexisting relationships between AAH/ACON and JCU researchers, the use of Solomon Islands Pijin, the involvement of community chiefs and the understanding and use of cultural constructs by facilitators all contributed to workshop success.
Limitations to the success of the workshop included considerable human and resource constraints. There is currently no dedicated health researcher at AAH/ ACON, with research activity being conducted in addition to regular duties (e.g. Director of Nursing, Principal of ACON, Medical Officer). Infrastructure limitations include minimal electricity (at time of writing: eight hours per day), limited computing, printing, telephone and intermittent and slow internet access. Many library materials are outdated. Despite these limitations participants from a variety of educational backgrounds participated in, and received benefit from, a responsive, culturally and linguistically accessible health research workshop.
Using an action research approach underpinned by decolonising research methodologies allowed Australian and Solomon Islander colleagues to utilise each other's skills and knowledge to collaboratively design, implement, monitor and evaluate the workshop. Utilising methods which included different options of time, location and language of delivery contributed to a culturally safe learning environment. Active learning methodologies allowed participants to build upon existing knowledges and more actively participate. The One Minute Reflections allowed rapid monitoring of each session and provided opportunities to modify subsequent sessions in response to participant's concerns. Having the workshop participants evaluate the workshop utilising skills learned during the workshop (focus group discussion There should be handouts-that would make it easier to understand  and data coding) and reviewing the results using an appreciative inquiry methodology re-enforced the utility of skills acquired or strengthened during the workshop. Collaboratively writing this publication and RA, HH and MRM presenting at an international symposium demonstrates the ongoing commitment to collaborative partnership. This paper is a description of an action research approach for a health research workshop at a remote Solomon Islands hospital. However, broader principals of: responding to an issue of concern from within the community; collaboration; honouring multiple knowledges; respect of difference; building on strengths; and flexibility are all relevant for conducting action research in other resource challenged, spiritually diverse and/or post-colonial contexts [19][20][21].
Participants have requested a follow-up workshop to cover a more comprehensive range of topics and to build on the successes of the initial workshop. A regular review of research activities and research infrastructure at AAH could monitor changing capacity and resource needs and collaborative research successes. Strengthening collaborative relationships between AAH, JCU, Ministry of Health and Medical Services (MHMS), Solomon Islands Institute of Medical, Training and Research Institute (SIMTRI) or other research institutions could create further opportunities to enhance health research capacity with the aim to improve health outcomes for people in East Kwaio and Solomon Islands. Ongoing support and collaboration is required at this remote Solomon Islands hospital to ensure initial steps to strengthen health research systems can align with local and national research agendas and ensure progress from 'research workshop' to 'research work'.