An analytic perspective of a mixed methods study during humanitarian crises in South Sudan: translating facility- and community-based newborn guidelines into practice

Abstract Background: In South Sudan, civil war worsened in 2016 leading to massive displacement in Juba that rapidly spread to other regions of the country. Access to health care is sparse due to attacks on health facilities and workers; pregnant women and newborns are amongst the most vulnerable in this context. The feasibility of implementing a new package of community- and facility-based newborn health interventions was assessed in displaced person camps during periods of sudden violence from 2016 to 2017. The case study aimed to understand implementation research outcomes such as acceptability, adoption, and other factors influencing implementation.Discussion: Countries with the highest neonatal mortality have recently experienced humanitarian emergencies and the translation of newborn guidelines into public health practice, particularly during periods of on-going violence, are not well understood or operationalized in these contexts. Unique challenges to conducting research in South Sudan included violent attacks against health facilities and workers that required implementing partners to modify modes of service delivery on an ongoing basis to ensure staff and patient safety. South Sudan faced devastating outbreaks such as a cholera and measles that shifted response priorities and then a new wave of displacement due to conflict resulted in staff relocation. Costs associated with transporting study staff and equipment kept rising due to hyperinflation, and study co-investigators were unable to return to South Sudan for some months following the July 2016 violence to conduct refresher trainings or monitor data collection. Strategies used to address these challenges were: collaborating with diverse partners to identify creative solutions; hiring locally-based research staff; maintaining flexible budgets and timelines; using mobile data collection to conduct timely data entry and remote quality checks; and utilizing a cascade training approach to train field researchers. Conclusions: The study provides lessons that are applicable to similar humanitarian settings, including the need for adaptable research methods, flexible budgets, innovative training, remote supervision, local researchers, and careful consideration of sociopolitical factors that impact access and safety of research staff. Engagement of community stakeholders can ensure data collection and interventions continue and findings translate to public health action, even in contexts facing extreme and unpredictable insecurity.