PEER RESEARCH IN ACTION III: ETHICAL ISSUES

Flicker, S., Roche, B., Guta, A.

PEER RESEARCH

IN ACTION III:

ETHICAL

ISSUES

Community Based Research Working Paper Series

The Wellesley Institute is a leading national non-partisan

research and public policy institute that is focused on

urban population health. We develop applied research

and community-based policy solutions to the problems of

population health by reducing health disparities.

We:

• conductresearchonthesocialdeterminantsof

health and health disparities, focusing on the

relationships between health and housing, income

distribution, immigrant health, social exclusion and

other social and economic inequalities;

• identifyandadvancepracticalandachievablepolicy

alternatives and solutions to pressing issues of

population health;

• supportcommunityengagementandcapacity

building including complex systems thinking;

• workinnumerouscollaborationsandpartnerships

locally, nationally and internationally, to support

social and policy change to address the impact of

the social determinants of health.

Our organization is a unique hybrid: while there are many

policy institutes and think tanks, no other institute in

Canada brings together research, policy, community

engagment and complex systems thinking, all focused

on developing pragmatic solutions to problems of urban

population health and disparities.

     III    

Acknowledgements

We would like to thank all the peer researchers and

service providers who participated in our interviews

and focus groups for so candidly sharing their stor-

ies. We really appreciated all of the work Chavisa Brett

did on this project. We would also like to thank Sarah

Switzer, Roxana Salehi, Sara Mohammed, Ciann Wil-

son, Britt McKee and Vanessa Oliver for their helpful

feedback on earlier drafts of this manuscript. Thanks

to Claudia Forgas for her careful editing of the papers.

Funding for this project was made possible through

the Wellesley Institute (WI), with additional ﬁnancial

support from the Centre for Urban Health Initiatives

and the Ontario HIV Treatment Network. This study

was reviewed by the Research Ethics Board at York Uni-

versity, Toronto.

About the Authors

Dr. Sarah Flicker is an assistant professor in the Fac-

ulty of Environmental Studies at York University and an

Ontario  Treatment Network Scholar. Her research

focuses on adolescent sexual health, HIV prevention,

and community based participatory research methods

and ethics. Dr. Flicker works across methodologies

(qualitative, quantitative and arts-based) and seeks to

partner with youth, students and allied practitioners

on action research agendas.

Dr. Brenda Roche is Director of Research at the Welles-

ley Institute. The Wellesley Institute is a Toronto-based

non-proﬁt and non-partisan research and policy institute.

Our focus is on developing research and community-

based policy solutions to the problems of urban health

and health disparities. Dr. Roche is trained in medical

anthropology and public health, her research experi-

ence includes community-based research on social

and health challenges for urban populations, includ-

ing trauma and resilience for marginalized commun-

ities. Her current work focuses upon conceptual and

methodological issues in participatory health research.

Adrian Guta holds a Master of Social Work (special-

ising in diversity and social justice) and is currently

undertaking doctoral studies at the Dalla Lana School

of Public Health and the Joint Centre for Bioethics, at

the University of Toronto. His dissertation research

explores the Canadian HIV community-based research

movement, with the aim of better understanding and

supporting ethical decision making in transgressive

research practices. Mr. Guta has co-authored several

articles on ethical issues in community-based research,

and emphasises the importance of ethical and meth-

odological reﬂexivity in his teaching. Mr. Guta is sup-

ported by an Ontario HIV Treatment Network student

award.

Peer Research in Action III:

Ethical Issues

Flicker, S., Roche, B., Guta, A.

         III

Executive Summary

ETHICAL ISSUES

This report is Part III of a series of working papers

that provides an overview of research ﬁndings from

our study related to the practice of peer research as a

strategy in community-based research (CBR) in Toronto,

Canada. In this section, we illuminate the particular

ways in which participants discussed ethical challenges

in their work when adopting a peer researcher approach.

Many participants articulated that the very decision

to engage in more participatory processes was an eth-

ical one. Nevertheless, new practices lay the foundation

for different ethical dilemmas. When probed, many

of our participants highlighted challenging ethical

moments which emerged from their CBR practices.

These included issues related to:

Formal ethics review: Those engaged in community

based research sometimes have difﬁculty navigating the

process. One strategy for dealing with this challenge is

to start thinking about ethical review early in the pro-

posal development process and as a group to identify

potential red ﬂags throughout the design.

Communication and power sharing: Many of the peer

researchers we talked to felt like they had limited power

and decision-making ability over the design or execu-

tion of project activities. Care should be taken to avoid

research practices that beneﬁt extensively from the

labour and expertise of peer researchers, but offers

little in return in the way of recognition, remunera-

tion or a sense of ownership of the work.

Conlicts of interest: Many participants suggested

that community members may be more inclined to

participate in a study if approached by a known peer;

however care needs to be taken to ensure that the like-

lihood of coercion is limited. It may be appropriate

to have someone who is more at “arms length” walk

through consent procedures and data collection.

Conidentiality: Conﬁdentiality is always an issue in

research. Peer researchers, like all staff with access to

private information, need support and training to adopt

careful protocols around privacy and conﬁdentiality.

Emotional triggering and the need to provide spe-

cial support: This phenomenon was experienced most

acutely by peer researchers who had past experience

with the topic under study (i.e. homelessness or drug

use) rather than those currently being impacted by the

issues. In these cases, peer researchers were sometimes

asked to return to environments where they encoun-

tered peers, settings, and dynamics that were at times

traumatic. The level of on-going support and super-

vision necessary to ensure that project needs are met

should not be underestimated.

Considerations beyond the life of the project: Peer

researchers may ﬁnd it difﬁcult to transition out of

the project.

Conclusion: Ethical issues are by their very nature

complex. There are rarely easy right and wrong answers

to challenging ethical issues. Careful ethical reﬂection

throughout the life of a research project can provide

a team with the opportunity to come up with creative,

attentive and just responses to these challenges.

WE ENCOURAGE COMMUNITY-BASED RESEARCH

TEAMS TO:

• Usetheformalethicsreviewprocessasanoppor-

tunity to reﬂect on broader ethical issues with the

entire research team.

• Aligntheirrhetoricofparticipationwithcommen-

surate power-sharing schemas and create transpar-

ent decision-making structures.

• Exploreissuesrelatingtoconictsofinterestandcon-

ﬁdentiality broadly and extensively in their training,

and ongoing support work, with peer researchers.

• Considertheemotionalimpactoftheworkthatthey

are asking of peer researchers and provide appropri-

ate mechanisms for ongoing support and supervision.

• Thinkabouthowtodevelopappropriatewrap-up

activities and a sense of closure.

     III    

Introduction

Community-based participatory research “empha-

size[s] the participation, inﬂuence and control by

non-academic researchers in the process of creating

knowledge and change” (Israel, Schulz, Parker, & Beck-

er, , p. ). The participation of community mem-

bers in research is believed to enhance the validity of

research ﬁndings and assist in ensuring that research

results are used to inform and foster social change at

the local level. The beneﬁts of community involvement

in research are well recognized; they include improved

access to and greater representation of marginalized

groups in research; data that are richer in quality and

more authentic in their representation; and the cre-

ation of opportunities for local capacity building and

empowerment (Minkler and Wallerstein ; Israel

et al ; ). These beneﬁts are often (although

not always) realized through authentic partnership

approaches that leverage the skills and assets of all

team members.

Community members are thought to bring exper-

tise that is informed by life experience to research

projects, including perspectives on the issues at hand

andinsightsaboutsolutions.Activelyengagingand

involving members of the community in research has,

however, not been without its challenges. Community-

based research initiatives are often better at establish-

ing partnerships among community representatives

(i.e., agency staff) than among community members

themselves (Flicker, Guta & Roche ). This ﬁnd-

ing raises critical questions about the assumptions

that underscore community involvement in research

(Dewar, ).

In an effort to achieve greater and more meaning-

ful community participation in research, a rise has

taken place in the number of projects that engage “peer

researchers.” Peer researchers (sometimes referred to

as PRs) are members of a research project’s target popu-

lation who are trained to participate as co-researchers.

In some cases, peer researchers partner in all facets of a

research project. In others, they are instrumental in one

or more aspects of a research project (e.g., participant

recruitment and/or data collection). To date, there has

been little critical discussion about the nature of peer

researcher participation in community-based research.

The dearth of data on peer research in practice has

meant that questions remain regarding the authen-

ticity of community participation, how power differ-

entials are addressed (if at all), and how participation

may impact the lives of community members in social

or economic ways that have not been fully appreciated

(Roche ; Greene et al., ).

The Wellesley Institute has created a three-part ser-

ies of papers examining the use of peer research as a

model of Community-Based research in practice. In

this series we consider Models of Practice; Manage-

ment, Support and Supervision, and Ethical Issues as

theysurfaceinthecontextofPeerResearchinAction.

Research Design and Methods

In , we began to examine community-based

research projects that adopted a peer research approach

to better understand () the processes (recruiting, hir-

ing, training, and managing) used with peer research-

ers in various aspects of community-based research; ()

the dynamics among peer researchers, their respect-

ive communities, and other members of the research

team/hosting organization; and () the ethical, social,

and practical issues that are particular to peer research

models.

Our study began with a working deﬁnition of peer

researchers as members of the target population who

are trained to participate as co-researchers. This def-

inition functioned as an important starting point and

reﬂects our observations as researchers engaging in

and supporting community-based research. In the

course of our study, however, we learned that the def-

inition of peer research and the role of peer research-

ers shift according to context, community, the nature

of the project, the understanding of community-based

research, and time.

Academicleadsandcommunitypartnerswhohad

used peer research models in their community-based

research in Toronto were invited to attend two focus

groups to identify and discuss ethical, social, and prac-

tical issues related to using a peer research model.

Most of those who participated worked as research

managers or staff at non-proﬁt agencies in Toronto that

were broadly engaged in addressing the social deter-

minants of health.

Peer researchers were recruited for individual

semi-structured interviews to discuss their experien-

ces. The peer researchers who participated reﬂect a

diverse group in terms of age, gender, sexual orienta-

tion, socio-economic status, culture, and ethno-racial

identity. Sixteen individual interviews were conducted

with peer researchers.

 Projects were identiﬁed from among those that had

been funded in full or in part by the Wellesley Institute.

         III

Interviews and focus groups were audio-recorded

and transcribed verbatim for coding and analysis. We

conducted a thematic analysis using a coding scheme

drawn from respondents’ verbatim accounts of their

experience. Coded data were analyzed and compared by

theme, range, and type of peer research involvement, as

well as the nature of the experience with peer research

for both service providers and peer researchers.

Ethical Issues

In Part III of our three-part series on peer research,

we provide an overview of the ethical challenges study

participants noted in their work when adopting a peer

research approach.

AsdescribedinPartIofthisseries,thoseengagedin

community-based research often describe the approach

in ideological terms. They are interested in democra-

tizing the research process and ﬁnding mechanisms

for those most affected by a problem to become part

of imagining new solutions. Many study participants

articulated that the very decision to engage in more par-

ticipatory processes was an ethical one. They argued

that conventional practices were often exclusionary

and served to disenfranchise the very communities

that health and social researchers were trying to reach.

Moreover, historical abuses of power conducted in the

name of research had left many communities angry and

uninterested in research engagement (see Schnarch,

). By changing the rules of the game, and including

peers in research planning and implementation, the

practitioners in our study felt that they were challen-

ging the status quo because it was “the right thing to

do.” Many invoked a moral argument, suggesting that

community-based research was an inherently more eth-

ical approach. This line of argument is echoed in the

literature. Other researchers have also written about

how adopting a community-based research approach

may be one strategy to redress historical inequities

(Malone et al., ).

Nevertheless, new practices lay the foundation for

different ethical dilemmas (Flicker et al., ). When

probed, many of our study participants highlighted

challenging ethical issues that emerged in their com-

munity-based research when they adopted a peer

research approach. These issues related to:

• formalethicsreview

• communicationandpowersharing

• conictsofinterest

• condentiality

• emotionaltriggeringandtheneedtoprovidespe-

cial support

• considerationsbeyondthelifeoftheproject

In addition, concerns around developing appropri-

ate models of inclusion, hiring and compensation, cov-

ered in parts I and II of this series, were also seen as

ethical issues.

Formal Ethics Review

Study participants identiﬁed a number of reasons for

undertakingaformalethicsreviewoftheirresearch.A

formal ethics review is often a requirement of funders.

In addition, having arms-length reviewers examine poli-

cies and procedures from an ethical perspective can

be very useful in illuminating unintentional potential

harms. Finally, gaining ethics approval by a large insti-

tution can offer an air of legitimacy:

[T]here was something about the University of

Toronto’s stamp on it, that I think actually had

a fair amount of weight … it made a difference

in terms of how we internally understood … how

much we were bound to do certain kinds of things,

or not. (Service Provider)



Nevertheless, those engaged in community-based

research sometimes have difﬁculty navigating the eth-

ics review process (Flicker et al., ). One strategy for

dealing with this challenge is to start thinking about the

ethics review early in the proposal development process

and to identify red ﬂags throughout the design. Dis-

cussing these potential issues with the entire research

team (including peer researchers) may help researchers

see problems in new ways and develop creative solu-

tions. The more documentation provided to review

boards about how you came to your well-reasoned and

thought-through approach, the less likely it is that you

willbeturneddown.Anotherstrategymightbetowork

with your university partners and contact the staff at

the ethics review board to help you think through dif-

ﬁcult issues prior to submitting your research proto-

col for review.

Very few of the peer researchers in our study were

involved in the upfront work of thinking through the

requirements of ethics review. Moreover, few of the ser-

vice providers played a role in this process. Most told us

 Many of our participantswere afﬁliated with academic

and community based organizations. We have chosen

to use the label “service provider” as a way to differen-

tiate these researchers from “peer researchers.”

     III    

Background, purpose,

objectives

• Howwasthecommunityinvolvedorconsultedindeningtheneed

for the study?

• Whobenetsfromthisresearch?

Decision making • Howwilldecisionsbemade?Whatrolewillcommunitymembers

or peer researchers have?

Research methodology • Howwillthecommunitybeinvolved?Atwhatlevels?

• Whattrainingorcapacity-buildingopportunitieswillbebuiltin?

Hiring staff • Whatskillsdothedifferentstaffmembersneedtohave?

• Whatongoingtrainingandsupportdodifferentteammembers

need?

Participants • Willtheresearchprocessincludeorengagemarginalizedordisen-

franchised community members? How? What kinds of support will

be put in place?

Recruitment • Whowillapproachpeopleaboutthestudyandhow?Whowillseek

consent? How can coercion (or the perception of it) be minimized?

• Howwill(realorperceived)conictsofinterestberesolved?

Risks and beneﬁts

• Whatarethepotentialrisksassociatedwithinvolvementforcom-

munities? For individuals?

• Aretherebuilt-inmechanismsforhowunatteringresultswillbe

dealt with?

Privacy and

conﬁdentiality

• Howwilltheboundariesbetweenmultipleroles(e.g.,researcher,

counsellor, and peer) be maintained or broken-down?

• Whatprocesseswillbeputinplacetobeinclusiveaboutdataanaly-

sis and yet maintain privacy of participants?

• Wherewilldatabestored?Whowillhaveaccesstothedata?How?

• Whatruleswillbeputinplaceforworkingwithtranscriptsorsur-

veys that contain identifying information?

Compensation

• Whowillbecompensatedforwhat?Whowillbeconsideredavol-

unteer? How will those decisions be made?

• Whowillhavecontroloverthebudget?

Informed consent

process

• Whatcould“communalconsent”looklike?

• Whosepermissionwillbeneededtotalktowhom?

• Whatmechanismswillbesetuptoensurethateveryoneinvolved

really understands all the risks and beneﬁts?

Outcomes and results • Howwilltheresearchbedisseminated?

• Whatarethenewwaysthatthisresearchwillbeactedupon?

Table 1

        

  

ExpandedandadaptedfromFlicker,S.,Travers,R.,Guta,A.,McDonald,S.,&Meagher,A.(2007).Ethical

dilemmas in community-based participatory research: Recommendations for institutional review boards.

Journal of Urban Health, 84(), –.

         III

that their academic partners had largely handled this

“hurdle.” Despite being uninvolved with the adminis-

tration associated with an ethics review, several par-

ticipants talked about how they had made important

contributions to improving recruitment, data collec-

tion, analysis, and dissemination (many of which are

arguably decisions about ethics).

Alloftheprojectsinourstudyunderwentaformaleth-

ics review, but there were some questions regarding the

degree to which university review boards are equipped

to deal with emerging new dilemmas in community-

based research (Guta et al., ). Most conventional

ethics reviews continue to focus their efforts on risks

and beneﬁts to individuals and do not take a commun-

ity-level perspective. Review boards often see research

as a short-term relationship that begins and ends after

signing a consent form and ﬁlling out a survey. Com-

munity-based researchers may want to take a broader

perspective when thinking about risks and beneﬁts to

the community as a whole. This is especially true for

those that see research as a communal intervention

that is part of a larger emancipatory agenda of com-

munity building and social development. Some ques-

tions that teams may want to consider that may not

necessarily be covered in a traditional ethics review

are outlined in Table .

Communication and Power Sharing

Invoking democratic ideals, many researchers write

about the importance of sharing power and ownership

with community members (Ross et al., ). Imple-

menting this ideal, however, is persistently challenging

(Flicker et al., ). Several participants in our study

highlighted the importance of transparent decision-

making and open communication regarding roles and

responsibilities:

People need to know where they stand and people

also need to know that we all understand each

other’s roles in the same way. They are import-

ant conversations to have … just to feel out how

people understood the roles in terms of hierarchy

and power … I mean it’s not power over in terms

of you’re a lesser of a person because you don’t

have letters behind your name or anything like

that. (Service Provider)

Nevertheless, many of the peer researchers we talked

to felt like they had limited power and decision-making

ability over the design or execution of project activities.

When peer researchers were asked whether they felt

ownership or had an opportunity to participate in lar-

ger project decisions, one responded:

I think I got a “don’t worry about it” … I feel a little

bit of a disconnect between what the coordinators

know and what’s ﬁltered down to me. So, I feel a

little bit of, like, they’re withholding knowledge

somehow … I feel a little bit on the outside. Like,

that I’m part of the experiment, and that doesn’t

sit that well with me. Cause I want to be included

in it … part of me thinks that … [at investigator

meetings] there should be at least … a represent-

ative of the peer researchers. (Peer Researcher)

In some projects, peer researchers felt totally includ-

ed in project decision-making, while in others, they felt

excluded. In instances of the latter sort, peer research-

ers articulated that it did not feel right to hear project

spokespeople using the rhetoric of participation when

they felt like that was not the case.

The effective inclusion of peers relies on attention

to power differentials and a commitment to shared,

transparent decision-making processes. Failure to

adopt these inclusionary practices runs the risk of

making peer involvement instrumentalist rather than

empowering.AsSimonandMosavel(2010)argue,

used in isolation from many more comprehensive

community-engagement approaches, peer research

involvement can easily become tokenistic or exploit-

ative. Care should be take to avoid research practices

that beneﬁt extensively from the labour and expertise

of peer researchers but offer little in return in the way

of recognition, remuneration, or a sense of ownership

of the work (Elliot, Watson, & Harries, ; Simon &

Mosavel, ).

Nevertheless, these dynamics are complex. One ser-

vice provider noted:

Can we comment on the decision-making pro-

cess, and what peers are involved in? I mean, in

some ways we try to involve the peers themselves

in terms of what they’d like to … but that brings

this very interesting ethical dilemma, conﬂict of

interest kind of complexity as well, because we

have peers involved in the advisory committee hav-

ing shaped the research, right, and its these peers

themselves, they often then get hired if there’s

actually data collection they can help with, what-

ever tasks, but in some ways we’re sort of strug-

     III    

gling about the conﬂict of interest, where we’re

in these decision making meetings, where we’re

saying, ok, we need to decide how many peers will

be involved in data, ok, what peers will be involved

in data collection, and analysis? … So, we’re strug-

gling with, maybe it’s a better system that people

on the advisory committee are notiﬁed beforehand

that they can’t be hired as actual research … sur-

veyors. (Service Provider)

Althoughcommunitymembersdidnotalwaysuse

philosophical language to talk about ethics, they were

more than able to describe when something simply

didnot“feelright.”Aswell,communitymembers

often spoke from a lived experience of having been

“researched” in the past, and could identify aspects of

the research process that made them uncomfortable

or that they would like to see used again:

[A]ctually,everymemberaroundthetable…has

been part of a study … and they actually have some

fairly strong ideas, that’s one of the places we start-

ed, was actually to talk about what it was like to

be interviewed, you know, what their experience

was like with research … we had done some of that

conversation about “how do you want,” “how do

you like to be treated?” (Service Provider)

Drawing on this rich experience can be beneﬁcial

in the planning stages. In one research project, peer

researchers argued that it was wrong to survey youth

about gaps and barriers to sexual health resources

(including basic information about STIs and HIV) and

leave without providing the needed information. In

response, the research team decided to follow survey

administration sessions with a sexual health educa-

tion workshop. The youth advisory committee mem-

bers also asked that the survey be administered in

community rather than school settings, as they were

worried about how other youth would feel ﬁlling out

the survey sitting near their peers and teachers (for a

full discussion of the ethical aspects of this study, see

Flicker and Guta, ).

Conﬂicts of Interest

In research ethics, conﬂicts of interest are commonly

understood to arise when a researcher has more than

one role (e.g., a physician conducting research on

his or her patients). The concern is that participants

may become confused about the difference between

these roles, and feel undue pressure to participate. For

instance, patients may participate in a study out of a

fear that their future care may be compromised.

In community based research, the beneﬁts associ-

ated with leveraging these complex relationships are

often promoted. For instance, peer researchers are

often encouraged to use their personal contacts and

stature to recruit their sometimes hidden networks

into a study. Participants highlighted the beneﬁts of

“peer-to-peer” interactions:

I think whenever you’re doing a project that’s

looking at marginalized communities, you bring

someone from that community into a leader-

ship position, it really sends a strong message

to the community you’re actually interviewing,

that you’re important, you can play a bigger role.

(Service Provider)

Indeed, peers highlighted the beneﬁts of being a

community member with a shared experience when

doing outreach with participants:

I think the fact that we were peer researchers …

they were more comfortable … I think it actually

improved the quality, the fact that they were very

comfortable. So they started talking, and they were

open, and they felt free with us. (Peer Researcher)

Many study participants suggested that commun-

ity members may be more inclined to participate in

a study if approached by a known peer rather than a

researcher that they did not know. Furthermore, it was

acknowledged that peers are often able to navigate hid-

den networks better than outsiders, especially when the

community of interest has been traditionally difﬁcult

to engage through research. Peer recruiters could be

a practical and benign way to overcome language bar-

riers and cultural differences when recruiting poten-

tialsubjects(Phillips,2010).Asaresult,mostofthe

studies we examined used peer researchers in their

recruitment efforts.

In contrast to a physician-patient relationship (where

a clear power differential exists), many participants in

our study felt that peers were better able to level the

playing ﬁeld and help participants make informed deci-

sions about participation. Nevertheless, a variety of

more subtle power differentials surfaced. Several peers

reported recruiting their close friends, intimate part-

ners, and/or family members into studies. They spoke

with pride about their ability to tap into these personal

         III

networks and how the inclusion of their contacts con-

tributed to the success of the research:

It could not have been done without the peer

researchers. Mainly, it could not have been done

without the people we knew. (Peer Researcher)

Often, peer researchers not only recruited these par-

ticipants but also were the ones to go through informed

consent procedures and data collection with their close

relations. This practice raises a number of ethical issues.

First, it can sometimes be very difﬁcult to say no to

someone you know personally. Similar to the physician–

patient example provided above, a close friend may

agree to participate in a study to avoid jeopardizing a

friendship (Bean & Silva, ; Phillips, ). On the

other end of the equation, a peer researcher may feel

uncomfortable about approaching those in his or her

close circle. In one study, a peer researcher described

how he stayed with an abusive partner in an effort to

minimize study attrition because he had recruited his

partnerintothestudy.Anotherissueweheardabout

was how challenging it was for some peer researchers

who felt confused by their dual role of researcher (who

maintains conﬁdentiality) and friend/family member

who felt compelled to become an outspoken advocate.

Others studies have also documented this challenge

(Elliot et al., ; Simon & Mosavel, ).

While peer researchers are able to leverage their per-

sonal networks to recruit, it may be appropriate to have

someone who is more at “arms length” walk through

consent procedures and data collection (Bean & Silva,

). When that is not possible, it is doubly import-

ant for peer researchers to reiterate to study partici-

pants that they are participating in research (not just

friendly conversations), and that they have the right to

refuse to participate and not answer particular ques-

tions (Molyneux, Kamuya, & Marsh, ; Ross et al.,

) . In fact, “refusals by community members are

not only acceptable, but potentially indicative of an

ability to make a choice” and should be seen as a good

sign (Molyneux, Kamuya, & Marsh, ).

Conﬁdentiality

I don’t think that … somebody who’s not skilled

in research wouldn’t have the capacity to pick up

the importance of the logic of conﬁdentiality. It’s

just getting that match in terms of maturity and

work ethic. (Peer Researchers)

Conﬁdentiality is always an issue in research. Peer

researchers, like all staff with access to private infor-

mation, need support and training to adopt careful

protocols around privacy and conﬁdentiality. However,

their training needs may be slightly different. They have

likely never had professional training on clinical ethics

that other members of the team may have undergone;

moreover, the concept of conﬁdentiality may be newer

for them. Furthermore, because of the close relation-

ships that peer researchers often have with research

participants, and the community at large, they may feel

increased pressure to share things that participants

have disclosed. However, we should not necessarily

assume that peer researchers will not honour the com-

mitment to conﬁdentiality. Many peer-researcher par-

ticipants in our study felt that they had been adequately

trained in this regard and were able to explain the value

of maintaining strict policies around conﬁdentiality.

Nevertheless, in some cases additional training may

be required to explore the challenges (and legal limits)

of discretion in close-knit communities. In response

to peers recruiting from their personal networks, one

researcher told us about how conﬁdentiality was dis-

cussed as an ongoing issue in the team:

[P]art of the debrieﬁng session was also to … re-

highlight the importance of conﬁdentiality, we

had done that before, but again, after learning all

that … and we wanted to double emphasize the

importance of conﬁdentiality. (Service Provider)

In this project, discussions of conﬁdentiality were

ongoing to make certain that all involved had a shared

continuing understanding of their commitment. In

another project, researchers only became aware of the

complexities of conﬁdentiality well into the project:

[S]o in this one we involved them in actually, they

helped in recruitment, they did the actual focus

groups, and then we realised, wait a minute, there’s

lots of complex ethical issues about actually involv-

ing peer researchers, peers interviewing or con-

ducting focus groups within their, among their

own peers. (Service Provider)

Conﬁdentiality of data may be more difﬁcult to

ensure when socially proximate individuals collect data

from each other (Bastida et al., ). It can be hard to

know how or why a secret becomes more widely known.

Issues of conﬁdentiality are not limited to data collec-

tion; they also need to be considered when analyzing

     III    

the data. Questions to consider include: Who will have

access to the data? In what form? For what purpose?

To what extent can the data by anonymous? How will

data be shared among team members?

Emotional Triggering and the Need

to Provide Special Support

Emotional triggering was another area of particular

ethical concern that emerged in our interviews with

study participants. This phenomenon was experienced

most acutely by peer researchers who had past experi-

ence with the issue under study (such as homelessness

or drug use) rather than those currently impacted by

the issue. In these cases, peer researchers were some-

times asked to return to environments (e.g., shelters

or needle exchanges) where they encountered peers,

settings, and dynamics that were at times traumatiz-

ing. These difﬁcult environments were often support-

ive of behaviours and lifestyles that peer researchers

were struggling hard to “move on” from.

Service providers described how the strategy of hiring

those with past experience of an issue was very useful

because these peers were likely to be more stable and

able to commit to project needs, and had an intimate

cultural understanding of the community. Neverthe-

less, some projects underestimated the emotional toll

that re-immersing peer researchers in spaces that they

had worked hard to leave behind might take:

Well, for me personally, um, it was a bit of an issue

because I … wasn’t really prepared for that aspect

of it—for whatever reason … It had more of an

impact than I thought it would … There [were] a

couple people who got emotional and upset about

certain issues. (Peer Researcher)

Some study participants described how they had tried

to prepare peer researchers for this challenge during

training. Others described how their teams instituted

ongoing support meetings with peer researchers to

debrief and assist peer researchers with the unantici-

pated emotional impact of the work. The level of

ongoing support and supervision necessary to ensure

that both project and peer researcher needs are met

should not be underestimated (Elliot et al., ).

Considerations Beyond the Life of

the Project

Whereas academics and service providers are often

hurried along to the next project or pulled back to pre-

vious commitments following the completion of a pro-

ject, peer researchers may ﬁnd it difﬁcult to transition

out of the project. This may be especially true when a

strong team has been developed, and peer researchers

become accustomed to regular support. Coordinators

should be wary of creating false expectations for indi-

vidual peer researchers that exceed the limitations of

anyonecommunity-basedresearchproject.Asmany

peer researchers are drawn in from existing services and

will continue to access those services, unmet expecta-

tions could create future problems in those relation-

ships if the beneﬁts of the project are not articulated

clearly from the beginning.

Furthermore, it may be important to think through

how to create closure and ensure that peer research-

ers ﬁnd other mechanisms for support after the pro-

ject ends. Many peer researchers talked about ongoing

project meetings as a time when they could personally

connect with others and get help with a variety of per-

sonalandworkrelatedmatters.Anabruptendtothese

activities might leave many vulnerable peer researchers

with a large void. Developing a thoughtful wind-down,

with some additional follow-up mechanisms may be

helpful for ensuring a smoother transition.

Conclusion

Ethical issues are by their very nature complex. There

are rarely easy right and wrong answers to challenging

ethical issues. While participants in our study were

quick to argue that adopting a peer research approach

was simply “the right thing to do,” when probed they

identiﬁed a number of new and emerging ethical

issues that resulted from this approach. Careful eth-

ical reﬂection throughout the life of a research project

can provide a team with the opportunity to come up

with creative, attentive, and just responses to these chal-

lenges. Failure to take the time to think them through

could have devastating consequences.

Recommendations

WE ENCOURAGE COMMUNITY-BASED RESEARCH

TEAMS TO:

• Usetheformalethicsreviewprocessasanoppor-

tunity to reﬂect on broader ethical issues with the

entire research team.

• Aligntheirrhetoricofparticipationwithcommen-

surate power-sharing schemas and create transpar-

         III

ent decision-making structures.

• Exploreissuesrelatingtoconictsofinterestand

conﬁdentiality broadly and extensively in their train-

ing, and ongoing support work, with peer research-

ers.

• Considertheemotionalimpactoftheworkthatthey

are asking of peer researchers and provide appro-

priate mechanisms for ongoing support and super-

vision.

• Thinkabouthowtodevelopappropriatewrap-up

activities and a sense of closure.

     III    

REFERENCES

Bastida, E. M., Tseng, T.-S., McKeever, C., & Jack, L., Jr.

(). Ethics and community-based participatory

research: Perspectives from the ﬁeld. Health Promo-

tion Practice, (), –.

Bean, S., & Silva, D. S. (). Betwixt & between: Peer

recruiter proximity in community-based research. The

American Journal of Bioethics, (), –.

Brugge,D.,&Cole,A.(2003).Acasestudyofcommun-

ity-based participatory research ethics: The Healthy

Public Housing Initiative. Science & Engineering Eth-

ics, (), –.

Elliot,E.,Watson,A.J.,Harries,U.(2002).Harnessing

expertise: Involving peer interviewers in qualitative

research with hard-to-reach populations. Health

Expectations, (), –.

Flicker,S.,&Guta,A.(2008).Ethicalapproachestoado-

lescent participation in sexual health research. Jour-

nal of Adolescent Health, (), –.

Flicker, S., Savan, B., McGrath, M., Kolenda, B., & Milden-

berger, M. (). If you could change one thing…What

community-based researchers wish they could have

done differently. Journal of Community Development,

(), –.

Flicker, S., Savan, B., Mildenberger B., Kolenda, K., &

McGrath, M. (). A snapshot of community based

research in Canada. Toronto: Wellesley Institute.

Flicker,S.,Travers,R.,Guta,A.,Macdonald,S.,&Meagh-

er,A.(2007).Ethicaldilemmasincommunity-based

participatory research: Recommendations for insti-

tutional review boards. Journal of Urban Health, (),

–.

Greene,S.,Ahluwalia,A.,Watson,J.,Tucker,R.,Rourke,

S. B., Koornstra J., et al. (). Between scepticism

and empowerment: the experiences of peer research

assistantsinHIV/AIDS,housingandhomelessness

community-based research. International Journal of

Social Research Methodology, (), –.

Guta,A,Wilson,M.G.,Flicker,S.,Travers,R.,Mason,C.,

Wenyeve,G.,&O’Campo,P.(2010).Areweaskingthe

rightquestions?AreviewofCanadianREBpractices

in relation to community-based participatory research.

Journal of Empirical Research on Human Research Eth-

ics, (), –.

Israel,B.A.,Eng,E.,Schulz,A.J.,&Parker,E.A.(Ed.).

(). Methods in community-based participatory

research for health. San Francisco: Jossey-Bass.

Israel,B.A.,Schulz,A.J.,Parker,E.A.,&Becker,A.B.

(1998).Reviewofcommunity-basedresearch:Assess-

ing partnership approaches to improve public health.

Annual Review of Public Health, 19, –.

Khanlou, N., & Peter, E. (). Participatory action

research: Considerations for ethical review. Social

Science and Medicine, (), –.

Malone, R. E., Yerger, V. B., McGruder, C., & Froelicher,

E.(2006).“It’slikeTuskegeeinreverse”:Acasestudy

of ethical tensions in institutional review board review

of community-based participatory research. American

Journal of Public Health, (), –.

Minkler, M. (). Ethical challenges for the “outside”

researcher in community-based participatory research.

Health Education & Behavior, (), –.

Minkler, M., & Wallerstein, N. (). Community-based

participatory research for health. San Francisco: Jos-

sey-Bass.

Minkler, M., & Wallerstein, N. (). Introduction to

community based participatory research. In M. Mink-

ler & N. Wallerstein (Eds.), Community-based partici-

patory research for health (pp. –). San Francisco:

Jossey-Bass.

Molyneux, S. , Kamuya, D., & Marsh, V. (). Commun-

ity members employed on research projects face cru-

cial, often under-recognized, ethical dilemmas. The

American Journal of Bioethics, (), –.

Phillips, T. (). Protecting the subject: PDR and the

potential for compromised consent. The American

Journal of Bioethics, (), –.

Roche, B. (). New directions in community based

research. Toronto: The Wellesley Institute.

Ross,L.,Loup,A.,Nelson,R.,Botkin,J.,Kost,R.,Smith,

G., & Gehlert, S. (). Challenges of collaboration

for academic and community partners in a research

partnership: Points to consider. Journal of Empirical

Research on Human Research Ethics, (), –.

Schnarch, B. (). Ownership, control, access, and

possession(OCAP)orself-determinationappliedto

research:AcriticalanalysisofcontemporaryFirst

Nations research and some options for First Nations

         III

communities. Journal of Aboriginal Health, (), –.

Shore, N. (). Re-conceptualizing the Belmont prin-

ciples:ACBPRperspective.Journal of Community Prac-

tice, (), –.

Simon, C., & Mosavel, M. (). Community members

as recruiters of human subjects: Ethical considera-

tions. The American Journal of Bioethics, (), –.

Wellesley Institute

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Peer research has emerged as a popular form

of community-based research (CBR) where

research projects include members of the

target population who are trained to participate

as co-researchers. The inclusion of community

members in CBR through peer research

initiatives is thought to enhance the quality of

the data collected, allow for the expertise of

lived experience to be incorporated over time,

while promoting capacity building at the local

level.

In Part III, we consider the particular ways in

which ethical challenges surfaced and were

addressed when using a peer researcher

approach. We consider issues related to formal

ethics reviews, communication and power

sharing on projects, conlicts of interest,

conidentiality, and the emotional challenges

that can accompany community based

research projects in action.

www.wellesleyinstitue.com

Peer Research in Action III:

Ethical Issues