Title: Centring participant experience: a realist evaluation of a menstruator-friendly facility
design project in a refugee settlement, Lebanon
Version: 4 Date: 09 Jan 2024
Reviewer's report:
Dear Editor, dear authors,
Thank you very much for the opportunity to read this important manuscript ahead of publication,
and congratulations to the authors for the endeavor of integrating formal research into
humanitarian program evaluation, it is not an easy task!
As an initial disclaimer, I have to admit that I am not familiar with the approach of realist
evaluation, and therefore I might have missed important nuances from the methodological point
of view. However, I hope I can contribute thanks my knowledge of the Lebanese context and
its humanitarian landscape.
I have greatly enjoyed the reading, and I believe with some clarifications this could be a great
contribution to the global literature on humanitarian health interventions.
In particular, I have appreciated the positionality statement, which I would rename as
“Researchers reflexivity and positionality statement”, as it goes beyond the description of each
researcher’s identity and affiliation, touching upon the ways in which the research team has
attempted to overcome the conscious or unconscious biases that might have played a role in the
interpretation of findings. I would add some information also on other authors, if possible, as it
would be interesting in particular to understand how the affiliation with the provider of services
in the settlement (be it from the IFRC or the LRC side) might have influenced the interpretation
of findings as well. In fact, while embedded researchers can bring a deeper understanding of
the programmatic dimensions at play, they might also present a conscious or unconscious bias
(either positive or negative) towards the program itself.
Background
It would be helpful if the authors could provide a description of menstruators, integrating the
disclaimers section into the background and providing references to it, including whether there is
any major controversy described in the literature on the identification of menstruators in general,
and in humanitarian settings in particular.
As a minor point, at the end of first paragraph: a reference is missing for the sentence “The
UNHCR estimates that 110 million people (1.4% of the global population) are currently forcibly
displaced – of these 29 million are menstruators”.
The final sentences of the second paragraph are unclear to me: is the need to be “respectful,
non-coercive, non-intrusive” postulated for the first time by the author? At the moment, it reads
like this, while I would argue it is a well documented need, with valuable practices documented
in literature. It would be helpful to engage with the global literature on participatory research
approaches and accountability to affected populations to highlight how these have informed the
study.
It would be helpful also, for readers not familiar with the topic, to list the “varying degrees
of participation” mentioned, as this would help understand the depth of engagement with
communities in this study.
The last paragraph of the background section, after the description of the aim of the research,
seems to belong more to the methodology than to the background, and I would suggest moving it.
Methods
It would be helpful to add some more information on the context: Qaa is an hard to reach border
area with over 100 informal tented settlements, where access for international humanitarian
actors has for long been problematic, and where the Lebanese Red Cross has managed to develop
a very cohesive and positive relationship with the Syrian communities – I have witnessed it
myself, it was impressive, so I believe explaining the hardship of the context itself would add
value to the paper!
Could the authors also specify how this one settlement was selected among the different ones
present in Qaa?
It would be helpful to understand whether menstruators other than cis-gender women were
involved in this research – considering the setting, I would be surprised if there were any, but I
would suggest nevertheless to make this point explicit.
I would suggest specifying the language in which the guide for interviews and FGDs were
produced, who translated them, whether they were back translated or not, and the language in
which both were conducted. I understand how that is intuitive for the authors – and for me –
but I believe it is an important methodological aspect to report on for the benefit of the broader
global humanitarian community for them to adopt/scale.
It would be helpful to clarify that FGDs were conducted in person, if I understood correctly.
I also wonder whether a more detailed description of the IFRC project would help? Not in
the main text, but maybe in the supplementary material, as project description? As the authors
righteously state in the background, there is such limited documentation of good practices in this
domain that making the methodology adopted available to the broader community of practice
could be really valuable.
Under data analysis, the authors introduce MCMO: it is the first time this acronym appears in
the manuscript, and it is unclear whether it relates to the CMO (Context-Mechanism-Outcomes)
configuration described before when introducing the realist evaluation approach, or whether it
is something different. It would be helpful to spell it out to help those who are not familiar with
the methodology – as in my case.
Results
The opening statement of the results suggests that there is one final programme theory. Maybe
it is due to my lack of familiarity with the methodology, but how does this one PT relates to the
9 PTs mentioned above, in the last sentence of the methods section? Perhaps it might help to
clarify how the 9 PTs emerging from the MCMOs were consolidated in one overarching PT?
The programme theories emerging from data analysis for the different phases of project
implementation are clearly described, with the authors striking the ideal balance between being
synthetic and detailing significant aspects for each PT.
Discussion
Minor point: please revise references, Spiegel is mis-spelled in a number of points.
I believe the discussion would benefit from some restructuring: there are a number of very valid
insights that emerge, and in the current form I feel they are not given the weight and visibility
they merit. I also have to admit that I am not a particular fan of headings and sub-headings in
discussions, as they interrupt the flow. I understand here they help in defining the rhythm and
indicating the move from one topic to another, but I would probably modify them, decrease their
number, and eliminate the sub-headings. One possible structure could be:
- Localisation of aid as operational approach to center participants’ experience: here, I would
perhaps emphasize less on the lengthy description of the IFRC, and highlight more the added
value of local actors in humanitarian responses, i.e. the LRC role, that is what is primarily
highlighted also by the participants. A similar heading could include what is currently under
“Wider contextual factors”, and it would propose a successful model that answers to the aim of
the research, rather than summarizing the findings.
- Participatory action research as a methodological tool to center participants’ experience: this
could include both the “Participation” and the “Implications of work” headings
- Limitations, as it currently is.
Of course, this is only a suggestion, and the authors will know better what they would like
to emphasize more, but to me something along these lines would provide more substance to
showcase what this study is contributing to, and would have a clearer link with the stated research
objectives.
Among the limitations, I would perhaps discuss how the fact that the affiliation to the LRC of
the only Lebanese researcher who was involved in field data collection could have influenced
the participants’ willingness to freely share their perspective. There is always a power divide
between service providers and service recipients, which is worth acknowledging.
Also, one point that could be discussed is how embedded researchers (IFRC and LRC) might
have helped or hindered unbiased evaluation of the project.
One additional limitation that could be discussed, provided that only cis-gender women where
involved as menstruators (if my assumption described above in the methods section is correct),
is that these results might not be generalizable to settings were other gender identities are present
as menstruators. Also, cis-gender women with disabilities might encounter more pronounced
barriers to access MHM services, so worth specifying whether they were represented or not.
Conclusion
I understand the manual is an IFRC manual, but the project sounds more a joint IFRC-LRC
project: it might be sensible to explicitly mention the LRC also in the conclusions, considering
their central role.
Ethics approval
It is not specified in the manuscript whether minors were involved as participants in the study.
As additional ethical considerations are granted for this group, it would be helpful to know how
they were defined and how their informed consent was sought.
I hope this can be of help and I wish the authors all the best for the continuation of their review
process.