Evidence-based practice (EBP) is the gold standard approach in physiotherapy, and it is essential that students are aware that it is the appropriate way to provide the patient with the best possible treatment. Undergraduate research (UR) can positively influence learning outcomes and research competencies related to EBP compared to traditional methods of higher education. The aim of this study was to evaluate the effect of implementing a research-based activity  in the UR programme on the learning and acquisition of research methodology-related competencies by first-year physiotherapy students.Students in the first academic year of the Bachelor´s Degree in Physiotherapy of University of Deusto  who were enrolled in the subject ‘Introduction to Research Methodology’ were invited to take part in a real RCT which consisted of three groups: intervention, placebo, and control group. While the RCT was carried out, researchers and/or participants roles were combined among students during the semester. At the end, a questionnaire that included open and closed questions was used to evaluate the effectiveness of the UR strategies used in students´ acquisition of theoretical knowledge, research competencies, self-efficacy of RCT skills and procedures. Lecturers also completed the questionnaire to evaluate their experience.From the 114 students enrolled in the subject, 102 participated in the RCT and 110 answered the final questionnaire. Regarding the development of research competencies, UR had a positive or very positive impact on critical thinking  and in the assessment of methodological quality . Furthermore, most students reported that the implementation of the RCT facilitated their knowledge of placebo, detection of bias, development of critical thinking and a better understanding of methodological issues in research. Lecturers reported an additional burden that was difficult to reconcile with daily duties.The novel UR program provided students with a new opportunity to improve their knowledge of RCT procedures, thus making the learning process more meaningful. Therefore, ways of teaching and learning focused on improving research and inquiry attitudes should be considered and integrated into the health care curriculum, especially in physiotherapy programs, to ensure the transfer of EBP for the provision of the best care.Australian New Zealand Clinical Registry: ACTRN12622000263796p (14/02/2022).The online version contains supplementary material available at 10.1186/s12909-023-04716-0. The development of research skills at higher education is considered a challenge where the institutions and lecturers try to combine educational and research attitudes, while inexperienced and novice students need to develop scientific skills . In thisEBP consists in the application of the best scientific evidence in clinical decision-making by integrating clinical experience, incorporating patient values and preferences into the practice of professional patient care . In healHowever, the term EBP should be clarified since it is considered a general, universal, and gold standard learning outcome for clinical practice rather than a specific education strategy per se . In thisEvidence supports that UR implementation increases motivation and develops an investigative attitude and vital general skills in students . Recent A real RCT where students could take part as researchers and/or participants as the main UR strategy was undertaken. The aim of the RCT was to evaluate the effectiveness of a superficial neuromodulation device developed by an external private company (© 2020 Irmoki). However, the true aim of the study reported here, to which students taking part were blind, was to evaluate the effect of the implementation of UR (through a teaching and learning strategy that included the design and active participation of students in an RCT) as described earlier.First-year students of the Bachelor’s Degree in Physiotherapy and the Bachelor’s double Degree in Physiotherapy and Physical Activity and Sport Sciences, who were enrolled in the subject ‘Introduction to Research Methodology’ at University of Deusto during the course 2021-22 were invited to participate in the study. The lectures are taught by two lecturers in three different languages . One lecturer was in charge of one group (the Basque group), whereas the other lecturer led the Spanish and English groups. The number of students for both lecturers was very similar, and they were strictly coordinated to teach in parallel, sharing content, teaching methods, schedule, and evaluation system. Indeed, the subject of “Biostatistics” was also shared between both of them. Finally, they can be considered as active researchers  in their background of musculoskeletal and respiratory physiotherapy area, respectively.It is worth mentioning that the University of Deusto implemented the Degree in Physiotherapy in the academic year 2020–2021. The emerging academic frame allowed the early integration of UR thanks to a curriculum designed according to guidelines set by experts , that alFor the sake of clarity, two types of procedures have been distinguished: first, those related to RCT procedures, and then those related to UR programme implementation.This RCT was designed following the Consolidated Standard of Reporting Trials for Controlled Studies (CONSORT) statement, registered with the Australian New Zealand Clinical Registry  and approved by the Research Ethics Committee of the University of Deusto (ETK-21/21–22). Details about the RCT are presented in Supplementary material A section.All students (n = 114) enrolled in the subject were invited to participate and informed about the RCT including potential effects and demands of the intervention. Four students refused to participate in the study and eight students dropped out during the 14 weeks due to failure to complete the weekly questionnaire, general discomfort associated with the device, and an ankle sprain. In the end, 102 students finally completed the RCT.Participants were randomly allocated to three groups . Students allocated into the intervention group wore a superficial neuromodulation device (© 2020 Irmoki) while students remained seated at rest following lectures at University. The device consists of 4 wireless receptors to be placed on the distal third of the limbs by means of gloves and anklets and controlled through Bluetooth technology by a smartphone app Fig. . The appSociodemographical data were collected at baseline. Outcomes were gathered by means of an online questionnaire at baseline and after weeks 2, 4, 6, and 8 which retrieved data about fatigue, sleep quality, muscular soreness, stress level, and mood. In addition, participants in the intervention and placebo groups were asked about the expectation towards the intervention and the perceived potential alterations.From 114 students enrolled in the subject, ergo involved in the implementation of the UR teaching strategies for 14 weeks, the same four students who refused to participate on the RCT also refused to answer the UR outcome evaluation questionnaires at the end of the semester. Thus, 110 responses were collected. In addition, the two lecturers completed the questionnaire.UR strategies were executed according to the subject´s syllabus. These were based, combined, and integrated on the theoretical topics described in Fig. The RCT, the implementation of UR strategies, and the evaluation were led by the two main lecturers of the subject. In addition, other lecturers from other subjects collaborated exclusively with the task of delivering and collecting the devices. In this sense, they also remained blinded to randomization and study information.“Cuestionario de Efectividad del Uso de Metodologías de Participación Activa (CEMPA)”  the integration of research knowledge related to the theoretical contents; (b) the development of research competencies; (c) the level of self-efficacy about the skills trained; and (d) the RCT procedures. The questions related to the first two dimensions were based on the validated version of the (CEMPA)”  which meo et al. . The queStatistical analysis was conducted using Jamovi . Descriptive statistics were calculated with proportions and frequencies and the distribution of the investigated variables was presented with bar diagrams.110 participants  years) completed the questionnaire about the impact of the UR teaching strategies. Figures  years) cRegarding the development of research competencies, most students reported that UR had a positive or very positive impact on critical thinking  and assessment of methodological quality  Fig. .Self-efficacy about the skills trained was highly rated, and skills that benefited the most were the ability to understand and explain the placebo effect, the capacity to read and integrate the results of an RCT, and the ability to identify bias and methodological gaps related to the design and execution of a clinical trial Fig. .Students evaluated very positively the inclusion of an RCT as an active learning strategy. Aspects that received the best evaluation were the adequacy of the UR strategy with the implementation of the RCT in the subject, the active participation of students during the learning process, and the involvement and structured organisation shown by the teaching staff responsible for the project Fig. .Answers from the open question are presented in Table On the other hand, negative aspects identified by both lecturers include the excessive duration of the intervention, the extra daily burden of getting students to wear the devices to ensure adherence to the intervention and data collection, and the difficulty of combining it with other daily obligations. However, lecturers reported that confidence in the premise of fostering research awareness, seeing it as the first step on a progressive path within a built UR programme, the support among the academic staff involved and their research experience helped to overcome the obstacle. Lecturers considered that this educational approach helped students to get closer to the reality of research, feel the placebo effect first-hand, identify mistakes and limitations, and propose solutions based on self-criticism. Lecturers also concluded that the activity provided a valuable opportunity for active learning through real experimentation.The research-based activity framed in a UR programme consisting of the implementation of a real RCT in which students were involved as participants and researchers, supervised by qualified lecturers, showed positive effects on the acquisition of theoretical content, the development of research competences, the level of self-efficacy in research skills and knowledge about RCT procedures. Furthermore, it provided a novel experience for students, making the learning process more meaningful.Strategies such as journal clubs or conducting a systematic review or meta-analysis are common in UR programs . In factIn our study, most students reported that UR had a positive or very positive impact on critical thinking and assessment of methodological quality. Likewise, student showed that the RCT implementation improved the ability to understand and explain the placebo effect, the capacity to read and integrate the results of an RCT. This means that the students integrated better key knowledge of RCTs, such us how design features, risk of bias or placebo effect may distort results and lead to incorrect conclusions and substantially modulate clinical decision-making in physiotherapy . In thisAccording to the EBP approach of the physiotherapy degree curriculum developed at the University of Deusto, the emerging framework enabled the early integration of UR and other innovative educational methods. Moreover, the inclusion of EBP education in early stages is an accreditation requirement for many health professional disciplines , 33. In The students evaluated very positively the adequacy of UR strategy, the active participation, and the involvement and structured organisation shown by the teaching staff. In this sense, the early and first-hand RCT experience within a subject related to research methodology, where students are actively involved in carrying out real research practical activities, fieldwork and/or act as participants is unique. This experience gave the students the opportunity to practise and become proficient at it, which has been described as an effective method to develop more sophisticated levels of intellectual development . AccordiThe positive effect related to the integration of the placebo effect was most often mentioned by the students. To the best of our knowledge, this is the only UR strategy that has led to a real experience of the placebo effect among physiotherapy students. When the placebo group was revealed, the students could integrate how different design features of a trial, co-interventions, sample contamination, ambiguity of symptom detection, patient’s or researcher’s biases can have a substantial impact on estimates of treatment effects. Therewith, we consider the impact on the students’ critical appraisal skill was truly outstanding through unusual, exciting, and surprising pedagogical learning.The acquisition of research theoretical knowledge related to scientific articles, journals, systematic review and PICO did not improve as much as other items. We conclude that the design of the RCT encouraged students to focus on the theoretical content that engaged them most actively. Otherwise, the RCT itself is not very related to this type of theoretical content. If the design used was a systematic review instead of an RCT, the opposite would probably be the case with regard to the topics of theoretical content which scored lower.Finally, the role of lecturers seems to be very important as an active knowledge transfer agent and the person who motivates, supervises, promotes, executes, and develops research linking students as technicians or voluntary participants during research procedures . In thisThis study has some limitations. A systematic pre-post semester analysis and the lack of a control group of students without UR implementation are the most important. In this sense, a control group was very difficult to achieve because it was practically unfeasible to blind the students to the implementation of the RCT. However, this should be taken into account when interpreting the results obtained. In addition, a long-term view in line with other research and inquiry strategies are required to evaluate the effect on the students’ learning process. Further, increasing the sample size of students should also provide more insights into the teaching and learning capabilities of research. Finally, the lack of validated tools and the use of different points and not well-balanced scales when dimensions were assessed also could have had a negative impact.This study presents a novel approach of the framework of UR in the unexplored healthcare discipline. Conducting an RCT is a challenging but valuable, useful, and effective way to integrate research and an inquiring attitude in physiotherapy students. Forms of teaching and learning focused on enhancing research and inquiring attitudes should be considered and integrated in the healthcare curriculum, especially in physiotherapy programmes, where students’ knowledge of RCT characteristics should be integrated early to ensure the transfer of EBP to provide the best care. In the future, this initiative should potentially be considered by lecturers, educational research promoters and stakeholders involved in UR programmes.Below is the link to the electronic supplementary material.Supplementary Material 1


Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana.Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance.The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy.For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy. Worldwide, about 810 women die every day from pregnancy-related and delivery complications. Although maternal mortality has seen a decline from 342 deaths per 100,000 to 211 deaths per 100,000 from 2000 to 2017 respectively, Sub-Saharan Africa and Asia still recorded 86% of all the deaths revealing the wide disparity across regions . CurrentSkilled attendance at birth, improved health facility delivery and family planning are key strategies that reduce maternal and neonatal morbidity and deaths. However, the proportion of births attended by skilled professionals is still below the recommended target particularly in sub-Saharan Africa where only about half of births are delivered by Skilled Birth Attendants (SBAs), 7. In GAuthors statement).The FMHCP was introduced by the Ghana government in 2003 with the aim of reducing financial barriers to accessing delivery services and to reduce the maternal mortality rate . The polThe aim of the implementation of the FMHCP under the NHIS as well as the Community-based Health Planning and Services (CHPS) strategies is to improve access to skilled delivery in Ghana . HoweverIn ensuring that Ghana makes good progress towards decreasing maternal deaths, ending preventable new born deaths and reducing new HIV infections as proposed by the SDGs 3.1, 3.2 and 3.3.1 respectively, efforts must be scaled up towards effective uptake of skilled birth utilization and the provision of quality skilled delivery services, to make it universally possible as advocated by the World Health Organization (WHO) .It is therefore expedient to explore the influence of the FMHCP under the NHIS policy-related factors on skilled delivery services in Ghana. This study will help to understand the main hindrances and gaps in the implementation of the policy and propose potential solutions that will effectively address the issue of bringing the residual non-users on board.This research was a narrative review of literature of factors influencing The FMHCP under the NHIS provision for skilled delivery services in Ghana.The research questions addressed were:What is the extent of coverage of the NHIS and its impact on skilled delivery?How does the implementation of the FMHCP under the NHIS impact skilled delivery services?What policy interventions should be put in place to improve the successful operation of the FMHCP under the NHIS to achieve the WHO SBA target in Ghana?To improve the chances of identifying all relevant literature, an extensive electronic search was done from the databases including PubMed, Science direct, Scopus, Popline, BioMed Central, google scholar, the webpages of National Health Insurance Authority (NHIA), and the World Bank. The keywords used for the search were: skilled birth utilization, skilled birth attendant/attendance, facility delivery, home delivery, maternal mortality, Free Maternal Health Care Policy, National Health Insurance Scheme, and Ghana. These terms were used in combination of terms such as ‘predictors’ or ‘determinants’ or ‘factors influencing’ and ‘Ghana’. Hand-searching of relevant references from included studies was also done and the full text of articles retrieved. Further, the guidance of scholars in the field was sought, for the right source of scholarly materials to be included.Peer reviewed and grey literature written in English Language and were published between 2003 and 2021 were included as the NHIS was introduced in 2003. Articles explicitly focused on Ghana including both descriptive and evaluative studies, were included in the study.Articles not written in English language as well as articles with dates earlier than 2003 and did not meet the required inclusion criteria were not included in the study.The first step involved the searching of databases  for peer reviewed articles on the research topic. Grey literature and technical reports were also searched on relevant websites. The second stage involved the exclusion of articles that are not relevant to the topic as well as duplicate articles. In the third stage, the articles left were assessed for eligibility by reading their abstracts. In the fourth stage, hand searching from reference list of included articles was done to retrieve more relevant articles. Next, articles that were not significant for the study were excluded from the fully screened/hand searched articles. In the final stage, peer reviewed articles and grey literature including technical reports that met the specific inclusion criteria were used for the review Fig. .The quality of the reviewed articles was assessed by authors using an adapted checklist developed by the Joanna Briggs Institute for critical appraisal , as descOut of the 26 articles that were used for the final review, peer reviewed articles were 22 and 4 were grey literatures. Of the peer reviewed articles, 19 were solely conducted in Ghana and 3 focused on Ghana together with other African countries. Also, out of the peer reviewed articles, 6 were explicitly primary data analysis , although no significant difference was observed .The perceived factors influencing the enrolment on the policy are: availability of health services, level of education , 22, cosMeanwhile, a new mobile renewal services was launched in December 2018, to enhance convenience of renewals, reduce the long waiting time of members and promote the scale up of population enrolment on the scheme . Indeed,The implementation and operation of the NHIS in Ghana is faced with many challenges . The FMHThe NHIS is predominantly funded from these sources; about 72.8% comes from Value Added Tax (VAT), 17.4% from Social Security and National Insurance Trust (SSNIT) contributions from formal sector workers, 4.5% from premiums from informal sector and about 5.3% comes from interest accrued from investments, donor funds, grants and other sources . IndividFurthermore, some design issues of the NHIS that threatens its long-term financial sustainability exist. Normally, insurance is funded by premia because, while membership increases, income from premia would also increase. However, in Ghana over 90% of NHIS funding come from SSNIT and VAT levy , 30. ThuIn addition, inadequate funding and poor sustainability of the NHIS results in delays in reimbursement and underfunding of health facilities and this leads to informal medical charges and out of pocket payments for some important services even under the NHIS , 32, 33.Although funding and sustainability is a threat to the management of the policy, operational challenges posed much more significant challenge  and leadMore so, the claim vetting system does not provide effective measures for the monitoring of service providers against possible fraudulent behaviors . CorruptAdditionally, the introduction of the new payment method for the NHIS referred to as Diagnostic Related Group (DRG) in 2008 has resulted in providers shifting to diagnosis that attract higher tariffs . AttemptThere are also concerns about abuse of the scheme by clients referred to as ‘client shopping’, where some NHIS subscribers move from one hospital to the other presenting the same medical complaints just to secure more medicines in order to sell , 39. SomThe National Health Insurance Authority (NHIA), is deemed as an independent regulatory body established to oversee the management of the NHIS, while its regional offices perform monitoring and evaluation roles over the district offices and service providers . This hoOut of pocket payments by pregnant women in health facilities, even with the implementation of the FMHCP under the NHIS, is an issue of concern , 41. In Additionally, there are reported cases of some health service providers extorting monies from clients possessing valid NHIS cards. Monies were extorted ranging from GH¢ 200 to GH¢400 before providing medicines and services such as C/S which were supposed to be covered by the scheme. But these monies were eventually refunded to the victims after a public outcry .Shortages of medicines on the National Health Insurance drug list in health facilities, coupled with the overwhelming workload on service providers, also potentially affects the quality-of-service delivery to clients, including maternity care , 40.This review found that the NHIS, which is meant to be pro-poor, promoting Universal Health Coverage by removing financial barriers to access, as well as improving SBA, has not been able to resolve inequities in enrolment, particularly among the poor and some rural dwellers, despite a general improvement in equity and population coverage of the NHIS. Coverage for free delivery care has many elements and it is necessary that countries choose the most appropriate interventions that will effectively address the inequities in access to SBA. For example, in Morocco a comprehensive free delivery care policy was implemented which also included transportation costs from the home to the health facilities in regions that have poor access. There has been a dramatic improvement for facility and C/S delivery in Morocco, especially among the poorest, over the past 20 years, which is attributed to multiple factors including policy interventions, which addressed both demand and supply side barriers to skilled delivery .This review showed that funding for the NHIS is relatively inadequate to sustain the scheme. Similar to this finding, the study of Witter, Boukhalfa  showed tThe financial sustainability of the FMHCP under the NHIS is linked with the structural design of the NHIS and operational challenges, which hinders the effective management of the policy and affects payment of claims to service providers. Ghana’s payment of claims to service providers is done retrospectively, which is the same as what is being practiced in Benin and Burkina Faso, while Morocco pays in advance to service providers on yearly basis in addition to supplying essential medicines and delivery kits . HoweverThese differences in payment of claims show the type of management approaches countries adopt. Unlike most countries where the policy is managed by the government through committees, just like what is being done in Ghana, in Benin, a centralized model was adopted where the management of the policy was being done by independent autonomous agency. This model adopted by Benin has substantially resolved delays associated with the policy . It is eEvidence suggests that, even with the implementation of a comprehensive fee exemption policy, household costs of provision of skilled delivery persist. For example, in Benin and Morocco, users were charged additional fees because service providers wanted to compensate for the free C/S, and all these are due to ineffective monitoring . This isThis review revealed that even though skilled birth attendance has improved utilization of skilled delivery, poor women are unable to utilise skilled delivery services compared to their rich counterparts, largely because the NHIS does not fully cover the cost associated with skilled delivery services. This is consistent with another study in Ghana .For an effective free delivery care policy to be successful in removing financial barriers and improving coverage for skilled delivery in Ghana, the government and stake holders involved in the implementation of the policy should increase funding for the policy and ensure its sustainability, as well as addressing the non-financial barriers identified.Most articles used secondary data in their analysis, which is limited in obtaining contextual understanding of the findings.This review has explored factors influencing NHIS provision for skilled delivery in Ghana. The study showed an improvement in SBA, however, barriers still exist that prevent some women from accessing skilled delivery care. One of such important barriers identified is that informal charges for some services covered by the NHIS persist. Similarly, ambulance services for referring pregnant women during emergencies are not covered under the policy and these challenges hinder access to quality skilled delivery services, especially for lower socioeconomic groups.The major cause of this, is the inadequate funding and poor sustainability of the NHIS, which results in delays in reimbursement and underfunding of health facilities.This review therefore proposes that, if Ghana wants to achieve the global target (90%) for SBA as well as the SDG targets 3.1, 3.2 and 3.3.1 by 2030, the NHIA should expand the coverage of the NHIS by absorbing all expenses associated with pregnancy and childbirth for the poor, including the cost of ambulance usage. In addition, the CHPS strategy needs to be strengthened by making the health workforce available, particularly in regions with no access to health services, in order to achieve effective equity in coverage of the policy. Also, the government of Ghana should increase funding for health and the NHIS, to promote the effectiveness and sustainability of the FMHCP under the NHIS in the provision of quality maternal health service.


Puerto Rico experienced four natural disasters in 4 years (2017–2021): Hurricanes Irma and Maria, thousands of earthquakes reaching 6.4 magnitude, and the COVID-19 pandemic. In this context, our team sought to understand the impact of disaster aid distribution on poverty and economic inequality, and their relationship to the spread of COVID-19 across Puerto Rico. Rapid research was required to ensure we could collect perishable data within this ever-changing context.Our mixed methods design relied on both secondary and primary data. Because analyses of the former were to inform where and how to collect the latter, timing was of the essence. The data sources identified were not readily available to the public, and thus required gaining access through direct requests to government agencies. The requests coincided with a transition between administrations after an election. This resulted in unexpected delays. Once in the field, the team had to balance the rapid nature of the research with the mindful work to avoid compounding traumas experienced by participants, heightened risk for re-traumatization and fatigue, the risk of COVID-19, the digital divide, and intermittent electrical and telecommunication services.In response to the delayed access to secondary data, we adjusted our research question. We continued to collect data as they became available, incorporating some immediately into analyses, and cleaning and storing others for future research opportunities. To overcome ongoing trauma challenges and prevent fatigue, we recruited and hired a large temporary team, including members of communities where we collected data. By recruiting participants and co-researchers at the same time and place, we both collapsed time between these activities and increased our team's contextual competency. To adapt to challenges presented by the pandemic, we created hybrid data collection procedures where some data were collected online, and some in person, while maintaining COVID-19 protections. We used similar adaptations for dissemination.Rapid research needs to be agile. Working within a convergence framework to investigate wicked problems had the unexpected added benefit of providing our team with a variety of disciplinary approaches which proved helpful in adapting to the changing conditions in the field. In addition to the resourcefulness of a transdisciplinary team, it is important to be willing to pivot in response to changes and to collect data where and when you can. To increase participation, opportunities need to be designed with flexibility, mindful of competing demands faced by individuals willing to collaborate. Collecting and analyzing data iteratively and utilizing local resources can enable rapid research that is rigorous and yields rich data.Our team applied the lessons learned to structure a rapid and iterative dissemination plan. We combined member-checking with community-level dissemination, enabling us to hone findings further before presenting to policy makers and media. Rapid research creates opportunities to make data-informed program and policy adjustments when they can be most impactful. Both the media and policy makers pay closer attention to research on current events. Hence, our recommendation is to do more rapid research! The more we do, the better we will get at it, and the more accustomed community leaders, policy makers, and program designers will become to using data to inform decisions. In this chapter, we draw from our experience as a transdisciplinary research team designing and simultaneously implementing rapid research in a post-disaster context. Using the convergence framework for transdisciplinary research  located in the Caribbean Sea, that had experienced in the span of 5 years a political-economic crisis, two Category 5 hurricanes , thousands of earthquakes ranging in magnitude and reaching up to 6.4 (December 2019 to early 2020) followed by the pandemic . Prior to the hurricanes, metrics for poverty and economic inequality in Puerto Rico were higher than any jurisdiction in the US Colón, : with thThe compound disasters Wachira,  laid barIn light of scholarship that indicated that current mechanisms for federal disaster aid and recovery correlated with accelerated economic inequality and increased poverty in the US  and a federal agency (Centers for Disease Control and Prevention).All primary data collection procedures were reviewed and approved by the Ethical & Independent IRB (case reference 20221–01), an independent Institutional Review Board (IRB) with a long history of reviewing public health research, an understanding of participatory research approaches, and an ability to review study designs and findings in Spanish and English. While our original intention was to use the IRB of our academic co-researcher located at a university, the pandemic added greater delays to their process timeline and threatened to delay our ability to collect primary data in line with our rapid research timeframe. Therefore, we decided to use an independent for-profit IRB that one of our research team members had worked with before. Ethical treatment of participants meant not only communicating informed consent in understandable language, but also discussing the additional protocol observed for reducing risk of COVID-19 transmission during research activities. The data gathered were anonymized prior to analysis and eventually preserved for subsequent analysis in the custody of the Puerto Rico Public and Applied Social Sciences Workshop (PR PASS Workshop), a nonprofit organization that provides technical assistance to researchers. The field team received training prior to heading to the field and had their interactions recorded and reviewed to ensure quality and corrections were made in a timely fashion.In the research implementation stage, thirteen of the fifteen members of our extended research team were born and raised in Puerto Rico, were bilingual in Spanish and English and had lived through the cascading disasters. Of the two who did not identify as Puerto Rican, one lived there and was bilingual.Our field research teamwww.prpassworkshop.org. Finally, all participants present at the town hall meetings were also invited to the policy seminar that was held virtually a month later. The final research report was also made available online in a Spanish translation.In these town hall meetings, our stakeholders were able to see and hear first-hand how their privacy had been protected. Stories were shared using fictitious names. The town names did not appear in our disclosure materials. Descriptions of the towns were rendered in ranges to assist in anonymizing the town and its residents. In an exercise of reciprocity and in service of accountability, communication products used in these events were shared, and still are available online for participants to review and comment at Authorship of the final report was offered to research collaborators. The process for inclusion was discussed during the on boarding of fieldwork assistants. The rule of thumb discussed, recognized that a contribution substantial enough to warrant authorship could be attained through consistent participation throughout the data entry, data gathering, analysis, town hall meetings, and policy seminar. In practice, this could be achieved by a student or community collaborator active in data entry, who also participated in the town hall meetings or the policy seminar, or by a fieldwork interviewer or participant that came to the town hall meeting, expressed interest in ownership of the recommendations and came to the policy seminar. To make this offer more attractive, research assistants were offered stipends throughout the project proportionate to the tasks selected. As an additional measure for inclusivity in the generation of knowledge, research contributorship was extended to all research collaborators. Other fields are increasingly using similar approaches used in other scientific fields which increasingly cite the CRediT (Contributor RolesTaxonomy) and decide for each project how many roles and contributions are needed to attain authorship  accelerated increases in poverty.Aim 2: Ascertain the influence of federal disaster aid on the change in poverty rates.Aim 3: Elucidate the relationships between hurricane damages, disaster aid, economic inequality and each municipality's ability to prepare for a public health threat, by investigating distribution of COVID-19 cases across municipalities.Aim 4: Identify potential underlying mechanisms of dynamic relationships identified in Aims 1–3 by exploring the impacts of federal disaster aid in two municipalities, using case study methodology.The aims were designed to have modular agility. Work pertaining to the first three quantitative aims were able to progress on their own with existing data while protocols and instruments were being developed and the independent ethics review board approval was attained. Correlation and regression models enabled analyses of municipal measures of damages, aid, poverty, economic equality, and COVID-19 burden. Results from Aim 2 guided our case study site selection for the qualitative study (Aim 4). Case studies were conducted to explore mechanisms of relationships identified at the macro level.To integrate findings from secondary and primary data we designed an iterative approach. While seeking protocol approvals and ethical reviews, we optimized time usage by focusing on secondary data gathering and quantitative analyses. Analyses of these data would inform where and how primary qualitative data would be collected. As researchers that were practitioners in disaster recovery zone after an election that generated change in federal and state government, our data plan included several proxies to account for delays or limited access to our preferred sources of data. In the case that data sources identified were not readily available to the public, we attempted to gain access through direct requests to government agencies.The research location for all aims was Puerto Rico. For the quantitative study aims, the municipality was the unit of analysis. We compared data for all 78 municipalities in Puerto Rico. The results from Aim 2 guided our case study site selection for the qualitative study (Aim 4). We identified the range of the resulting correlations between disbursed aid and changes in poverty in all municipalities and then selected one of the three municipalities with the average correlation and the municipality with the farthest outlier correlation . All correlations were positive, and clustered around the averages, leading us to believe that conducting a case study in one of the three municipalities with the average correlation could potentially illuminate possible broader underlying mechanisms contributing to the observed positive relationship between federal aid distribution and increasing poverty. In the vein of appreciative inquiry, we felt a comparison between the municipality that exemplified the correlation and the municipality where federal aid seemed to have the smallest impact on increasing poverty would help identify potential mediating factors reducing the intensity of the relationships.Since there were three municipalities with the average correlation, we were able to select two municipalities in the same peri-urban region. Primary data collection for Aim 4 was conducted in person in the two selected municipalities. In order to extend privacy and honor confidentiality agreements we referred to the sites with the fictitious names Nube and Suelo. Nube was a municipality with a population of under 40,000 people and was described by residents as “campo” . Nube represented the average positive relationship between aid and poverty in PR. In Nube, over a 7 year period, the percentage of population living below poverty level (PPBPL) grew by 4%. Suelo, on the other hand, was the municipality with the smallest identified relationship between aid and change in poverty . Its population was ~70,000 and it had both rural communities and more suburban developments. In Suelo, the PPBPL decreased by 19% over the same period.The study methodology is described more in-depth elsewhere  accelerated increases in poverty.Poverty was measured as the proportion of the population whose income fell below the U.S. Census poverty line. The fact that these datasets are already readily accessible made attractive for our rapid mixed methodology. We estimated the changing rate of municipal poverty by calculating the relationship between year and poverty while holding constant other changing demographic measures including: U.S. Census estimates of the total population, proportion of the population with a bachelor's degree, percent of the population below age 18 and above 65 and the Puerto Rico Department of Labor's quarterly average wage. We then calculated the relationship between year, total population, and poverty for each municipality separately. By calculating the difference between the year coefficient pre-2017 and the year coefficient post-2017, we were able to approximate how much the change in poverty rate altered after the hurricanes. Using this as a dependent variable, we examined the relationship between this alteration and hurricane damage, conceptualized as both property damages and fatalities. Hurricane property damages were approximated with the Special Hazards Events and Losses Database for the US (SHELDUSTM) non-crop property damages and fatalities were calculated by the Puerto Rico Center for Investigative Reporting.Aim 2: Ascertain the influence of federal disaster aid on the change in poverty rates.For Aim 2, we built on Aim 1's models by adding data from the FEMA and Community Development Block Grant Disaster Recovery programs on their aid distribution in each municipality. Our key independent variable for this analysis was the total disbursed aid including assistance to individual households and assistance to municipalities. This data was readily available online in an easy to use format.Aim 3: Elucidate the relationships between hurricane damages, disaster aid, economic inequality, and each municipality's ability to prepare for a public health threat, by investigating distribution of COVID-19 cases across municipalities.For Aim 3 we used Puerto Rico's Department of Health municipal COVID-19 cumulative case counts from April 2020 to April 2021. We included non-duplicated positive PCR and serology tests. We calculated correlation estimates between COVID-19 case counts and total aid disbursed, number of fatalities attributed to Hurricane Maria, total damages in dollars, and the Gini coefficient for each municipality. Raw data used was available online but required processing to arrive at the format and quantities used in our analysis.Aim 4: Identify potential underlying mechanisms of dynamic relationships identified in Aims 1–3 by exploring the impacts of federal disaster aid in two municipalities, using case study methodology.n = 76) to collect data. Interview guides were developed to focus on factors in multiple eco-social dimensions. Areas of interest, curiosity, and confusion for further exploration were identified by the research team in the process of discussing results of Aims 1 and 2.We used ethnographic observation and structured interviews , and 56 unaffiliated residents. The poverty rates of those interviewed reflected the overall poverty rates in each municipality see .N = 76, because all but three business owners were also residents). Finally, we examined correlations between hurricane damages, hurricane fatalities, disbursed aid, economic inequality, and COVID-19 cases. For further information on participant demographics by municipality  into our analyses. The SVI was developed by the Centers for Disease Control and Prevention for this purpose, and as defined by the U.S. Census, “The Social Vulnerability Index uses U.S. Census data to determine the relative social vulnerability of every census tract.” The SVI ranks each tract on 14 social factors and groups them into four related themes. Each tract receives a separate ranking for each of the four themes, as well as an overall ranking. The SVI can help emergency response planners and public health officials identify and map the communities that will most likely need support before, during, and after a hazardous event.When incorporating the SVI into our research, we kept in mind that vulnerability is not a static experience where all 14 social factors remain equally relevant across time and place. Our review of the CDC's SVI index let us to use a modified version of the SVI that had been adapted to the Puerto Rican context. For example, the CDC version included the percent of non-English speaking population did not provide the same kind of information it did in the US because Spanish is the official and commonly used language across all of Puerto Rico's municipalities. Non-Hispanic, white population percentage was also not very meaningful due to the fact that nearly all residents of Puerto Rico identify as Hispanic or Latino. Thanks to the generosity of colleagues at the Vulnerable Coastal Communities Initiative (VCCI) of the Center for Community Progress, we were able to use an SVI, measure modified specifically for Puerto Rico, henceforth referred to as VCCI-SVI.For Aims 1, 2, and 3, we estimated panel and cross-sectional regression models and correlations. For Aim 4, we used a hybrid inductive/deductive thematic analysis technique outlined by Fereday and Muir-Cochrane  to iteraLocal government representatives, research collaborators and participants were all invited to a 2-h data review meeting with the three co-principal investigators. Invitations were municipality specific. It was an opportunity to dispute or validate the data, eco-social models, and thematic analysis. At the meeting, the researchers shared graphic representations of results from both municipalities, revealing only which data belonged to their municipality, and referring to the other by the code name, either “Nube” or “Suelo,” accordingly. The meetings also allowed researchers to discuss potential recommendations to government agencies and gave room for residents to discuss their own takeaways for improving local preparedness. To incentivize participation throughout the value-chain of knowledge generation, participation in all meetings carried participation stipends for participants and research assistants.Once the findings and policy recommendations were validated by participants, these were presented in a policy seminar, which included participants from federal government agencies  and local government officials , in addition to academic representatives (Chair of Department of Economics at the Interamerican University). The seminar was held at a local university and open to the public both in person and virtually, with students particularly encouraged to attend. A handout summarizing the findings and three data-informed action items was produced and disseminated at each event and online, in Spanish. Additional dissemination efforts in both languages were planned news media and professional meetings, including the following: the Natural Hazards Center Researcher Meeting, the Society for Applied Anthropology, a seminar hosted by the Puerto Rico League of Cities and followup meetings with government officials.Our mixed methods design relied on both secondary and primary data. Because analyses of the former were initially designed to inform where and how to collect the latter, careful time-management was needed. The research team had anticipated some challenges in gathering data due to the post-disaster context while in the middle of a pandemic and because of inconsistencies in data management across the US with regards to its territories. The coincidence of our research with the change in state government administration, generated additional delays that threatened the initial linear progression of research tasks.As proposed, our research sought to replicate the analysis performed stateside by using the exact federal data sources for Puerto Rico. Though many federal sources, like the U.S. Census Bureau, US Department of Labor, US Economic Development Agency and data from the Center for Disease Control and SHELDUSTM are readily available online for the 50 states, they are not similarly available for US territories and treated differently across agencies. At times, municipalities were treated as counties, in other reports counties were regions of municipalities. Some reports were not available for territories at all, creating “data deserts,” which our experience suggested may be applicable to all US territories that are often left out of databases that tally states, but not territories. For the data we did get, we found it important to “trust but verify” all data. For example, we obtained the urban-rural measure from the National Center for Health Statistics that other researchers rely on to describe the degree of urbanity/rurality, in the knowledge that it greatly impacts many social, economic and health outcomes. Upon inspection, we realized that the categories, as applied, did not reflect a realistic understanding of Puerto Rico's geography; therefore, we created a population density measure that was imperfect but, we felt, better captured the true impact on infectious disease risk. To measure economic inequality we used the Gini coefficient for each municipality.Going into the research, we knew many local sources of data were not readily available online and anticipated this might be problematic. This was especially relevant in accessing up to date local health data. COVID-19 incidence reports, for example, were provided daily online but datasets were not readily available for download nor organized into monthly totals by municipality introducing steps prior to data analysis. Personal appeals for specific or better data to government agencies were difficult due to the impact of post-election administration changes at the federal, territory, and municipal levels. With no easy online choices available, we decided to enter health and COVID-19 data manually in order to process it as needed.Once in the field, the team had to balance the rapid nature of the research with a mindful approach to participants with a heightened risk for re-traumatization, anxiety, illness due to COVID-19, or fatigue. Inviting participants at random in public spaces had only moderate success. Still-fragile, intermittent telecommunication services added difficulty to coordinating interviews from afar. In the process of enlisting the collaboration of organizations, business leaders made it apparent that their operations were struggling to do more with fewer staff because in many cases they had just reopened and were trying to offset the pandemic-enforced closures. Other organizations were on limited schedules or had closed permanently due to COVID-19. “Free-time” to advance research was a luxury few could afford. In the face of these challenges, the team pivoted to work through social networks of trust.Field research assistants from each study site took interviews as an opportunity for them to check-in and share stories with people they knew or were referred. This was an opportunity for the study to incorporate voices that would not be easily accessed in public spaces. Out of concern for accidental bias from occasionally familiar or emotionally engaged interactions, at least two members of the research team reviewed the interview transcripts to review interactions and to provide timely feedback. The observed trend was that when interactions were familiar, the process was more conversational but ultimately followed the questionnaire. Another strategy used to address bias, was the early sharing of data and findings with participants in town hall meetings.In response to the delayed access to secondary data, the Co-PIs adjusted their research question. They also changed the rationale for selecting the municipalities for the case study (Aim 4) by looking a the relationship between poverty and distribution of funds (Aim 2) rather than informed by taking into consideration health data as well (Aim 3). This allowed the project to collect and analyze data as they became available, incorporating some immediately into analyses, and cleaning and storing others for future research opportunities.To overcome ongoing trauma challenges and prevent fatigue, a large research team was recruited that included members of communities where we collected data. By recruiting participants and co-researchers at the same time and place, we both collapsed time between these activities and increased our team's contextual competency. To adapt to challenges presented by the pandemic, we created hybrid data collection procedures where some data were collected online, and some in person, while maintaining COVID-19 protections.Between April and July 2021, FEMA held a Public Comment Period on Climate Change and Underserved Populations. In order to take advantage of this opportunity to share recommendations within the agency's timeframe, the Co-PIs preemptively developed and shared recommendations prior to the planned discussion and validation process with local stakeholders. The change in the order and process of collaborative review of findings and generation of recommendations reflected the Co-PIs priority on using findings to guide decision making in government disaster response policies. Once these findings initial findings were shared with FEMA, they were also presented, discussed, and expanded through the town hall meetings. This adaptation to the initial plan of events, reaffirmed the research teams' understanding that systemic change requires an iterative approach using a variety of engagement strategies.relationships-between-distribution-of-disaster-aid-poverty-and-health-in-puerto-rico. In this section, we provide a broad overview of our findings and reflect on the role of our methods in attaining the original study aims. Readers are invited to visit the report for more details, including tables and graphics in accompanying appendices.The study results are described in-depth in a report submitted to and published by the Natural Hazards Center of the University of Colorado, Boulder, available at: The co-researchers anticipated their original research might find a positive relationship between disaster aid disbursed, accelerated growth in poverty and elevated economic inequality, at the municipal level. Quantitative analyses did reveal the expected patterns across all municipalities. This outcome was expected based on the research described in the introduction by researchers in the US. Our findings did support the expected outcome. In addition, we learned from primary qualitative data about potential reasons for the identified relationship between aid and economic outcomes. We further expected to find a pattern of relationships between COVID-19 positive cases and increased poverty and economic inequality. This expectation was based on decades of scholarship connecting economic inequality and poverty to poor health outcomes, across multiple causes of morbidity and mortality. Qualitative analyses contributed to identification of both potential pathways of causation and public health and policy recommendations.When we look at the methodology used to complete the research, we had two expected outcomes. First, the Co-PIs expected the choice of using local research assistants would enable rapid data collection and ensure the experiences of marginalized populations were included. Second, research team hoped that through the rapid dissemination efforts we would see a growth in ownership of the knowledge generated in the form of interest and efforts that would result in shared authorship or the continued participation of participants from town hall meetings in the policy seminar. As for mid to long-term outcomes, we expected to see changes in how FEMA distributes aid and measure the success of their distribution efforts.After accounting for the impact of changes in population, municipal poverty rates began increasing faster post the 2017 hurricanes. We found this increased rate was positively correlated with hurricane fatalities but not hurricane property damages. Moreover, poverty accelerated at a faster pace in areas that received more disaster aid. Case studies provided a disaggregated view of disaster aid showing its unequal distribution. Aid flowed, just not everywhere with ease, and more importantly, it was rendered out of reach for already marginalized populations. Its unequally distributed flow was in turn associated with increased health inequities. Interviews highlighted the post-disaster growth of extreme poverty and themes of structural violence. We found similarities between the two municipalities, such as an overall sense of violence from bureaucracy and governmental neglect, that were commonly connected to the economic and health costs of delayed and inequitable disbursement of government aid. We also found differences, such as a fluctuating resilience reserve where poverty was less extreme and more enduring hyperlocal support networks where extreme poverty created “everyday disasters” that required unending survival responses. Lastly, we found cumulative COVID-19 cases to be positively correlated with each of the following, ordered from strongest correlation to weakest: disbursed disaster aid, hurricane fatalities, economic inequality, and hurricane property damages.In examining results of our methodological choices, we find mixed results. Recruiting research assistants from the municipalities studied gave us access to 75% of the primary data analyzed. By virtue of living, working or having relatives in the study sites, local research assistants were able incorporate participants experiencing economic duress, who felt they were sidestepped by a variety of disaster assistance efforts, and who were struggling to rebuild their lives. Some of these participants had multiple part-time jobs and had limited free time, others were not employed but did not have access to technology, had fear of contracting COVID-19 because of underlying conditions, or held a high distrust of strangers. The success of this early collaboration with research assistants did not guarantee, however, consistent, extended participation throughout the final stages of the study. Rapid dissemination activities did meet expectations, successfully engaging a variety of audiences including municipal government employees, residents, representatives from state and federal agencies, leaders of nonprofit organizations, professors, and students from a variety of fields. Though town hall meeting participants did not become repeat participants in the policy seminar, members of the research team were able to establish repeated meetings with FEMA employees to discuss findings and potential course of action to enhance equity in disaster recovery.The two main advantages of the study design were: (1) the interdisciplinary convergence framework and (2) the use of rapid data collection with rapid dissemination in order to contribute to real-time decision-making. Our team found that it was especially essential in disaster research to go beyond interdisciplinarity and actually build each other's capacities. Thanks to the interaction and know-how from each discipline represented, we were able to move quickly enough to capture perishable primary data while also utilizing available secondary data to guide research decisions. Primary data collection in a disaster recovery context is in itself challenging. The added anxiety of a global pandemic made interacting with strangers appear threatening. Intermittent electricity and internet access could offset this for some, but the digital divide marginalizes many experiences from being included. These filters to participation were offset by recruiting local research assistants to complement the data using their social networks to represent often overlooked populations. Our focus on disseminating and validating findings in the communities studied advanced not only the rigor of the study but also created a space for local actors to share ideas of how to more effectively coordinate assistance in their communities.While the rapid pace of the research was a strength for its applicability, it was a limitation when it came to the depth and breadth of our findings. The team had to cut some of the original research objectives when encountering obstacles in accessing secondary data in a timely manner and minor delays in receiving approval for ethical human subjects research protocols. While we were able to conduct two in-depth case studies in two sites selected with guidance from our quantitative findings, more time would have created the ability to contextualize the primary data within an in-depth review of secondary data from each municipality, providing even more information on potential causal pathways and potentially effective recommendations for public health and disaster aid distribution strategies.Time constraints limited the ability of the team to engage with local communities and the findings in more meaningful ways. Participants, research assistants and municipal collaborators all faced a variety of competing interests and limitations. As it would happen, though we celebrated town hall meetings, some participants could not travel at night or coordinate assistance in time. Research assistants all faced a variety of opportunities and changes in priorities. Some students moved away, others found jobs, or internships. In the end, for a variety of reasons the invitation to continue their collaboration and become co-authors did not get the traction we had hoped. With more time, a variety of activities or means of engagement could have been divided to extend participation.The overarching objective for the research was to conduct rapid research in order to inform policy and practice during the recovery period. Though the research responded to a special call for proposals by the Natural Hazards Center and received funding from two federal agencies, National Science Foundation and Centers for Disease Control and Prevention, many recommendations were for yet another agency: FEMA. As a result, though our work was federally funded, it was not “located” within the agency whose policies our recommendations addressed. This external positionality limits the ability to inform or account for change. The public invitation to share recommendations with FEMA via an online submission democratizes participation to reflect upon practice and incorporate data from research, but at the same time it invisibilizes the authors and interactions that inform changes.Our rapid dissemination efforts attempted to facilitate systemic change by implementing a variety of engagement strategies: online webform submission, letters, individual meetings with municipal and agency leaders, town hall meetings, and a policy seminar that was both in person and virtually transmitted, but it is difficult to know the extent of the impact. The policy seminar organized by the research team provided a more visible chain of events that revealed institutional limitations to engage with local researchers. In subsequent interactions, as next steps and proposals for action were mentioned, local FEMA representatives informed the research team of their limited control over the decision-making process that made it possible to consult or provide solutions informing policies or practice. Contracting decisions are determined in central offices off the Island. Potential engagements would further require that contractors be able to provide professional services in a regional scale. The search for system-wide services and the generalizability of solutions for use in a multi-state region or nationwide, brought into focus potential systemic barriers to collaboration with local scientists and organizations. At the time of writing this chapter, beyond any rapid timeline, members of the research team are still in conversation with different government stakeholders exploring ways to increase awareness of how current aid distribution strategies contribute to greater social inequities and challenge disaster preparedness and public health.Our study aimed to replicate a quantitative approach to research as a first step to exploring relationships and patterns that could inform location-specific recommendations. As described in the methods section, we engaged in transdisciplinary analyses of our data, recruited research assistants from the case study sites to reach voices that may be repeatedly marginalized from aid and from representation in the public construction of knowledge, and adopted an iterative approach to communicating disaster research findings in order to advance its broader use. While our methods are replicable, we hope that future research replicating our methods may engender results that can change the way aid is distributed so that it contributes to increased economic equality and health equity. This would move the disaster response and recovery field toward identifying policy and programmatic interventions that practitioners could then strive to replicate.Our team considers that research in a post-disaster context should ethically strive to be immediately useful to the current and local context where the research is conducted. Transdisciplinary teams with a willingness to break from disciplinary tradition, mixed methods, local engagement and rapid dissemination are key to this direction. In this section, we provide lessons and recommendations that emerge as a product of our reflection.Architect Luis H. Sullivan coined the phrase “form follows function” in 1896. In the context of cascading and compounding disasters, it is essential to introduce both rapidity and agility to the methods design to ensure data collection and analysis can provide useful findings in timely fashion. We knew that with each passing day, the experiences, perspectives and ideas of potential research participants were likely to change. Memories of the disasters were prone to recede even more quickly than usual as earthquakes hit, followed by the COVID-19 pandemic. Fear of the unknown and safety occupied evermore brain activity, increasing the perishability of the data regarding Hurricane Maria disaster assistance. The research timeline and methods needed to fit the changing context in order to meet our research goals. Working within a convergence framework to investigate complex problems had the unexpected added benefit of providing our team with a variety of disciplinary approaches which proved helpful in adapting to the changing conditions in the field.The form of our research team was developed according to function: the guiding research question required a public health expert, an economist, and an applied anthropologist. The public health researcher-practitioner helped to draw the connections between meteorological and fiscal disaster outcomes and health risks and outcomes. The economist contributed an understanding of the measures of poverty and economic equality, and statistical skills that our quantitative study aims relied upon. The applied anthropologist contributed not only experience and knowledge with qualitative ethnographic methods, but also connections to several communities, from local community case study sites to territory-level policy-makers. We knew this, and celebrated these complementary strengths, from the moment we came together.Having these different skill sets enabled us to pivot quickly when we encountered a delay so that we could continue forward momentum and collect enough data to contribute to answering our research questions within less than half a year. Originally, we had planned to finish the first three aims and have the findings guide us in selecting the municipalities. Faced with delays, we adopted the public health orientation used in epidemiological studies around selecting units for comparison based on matching other potential impacting factors in an attempt to “isolate” the variables of interest. The investigation was informed from the field of anthropology through prioritizing relationships. The anthropologist visited several communities selected, relying on preliminary quantitative findings and matching communities on other characteristics.In addition to the resourcefulness of a transdisciplinary team, it is important to be willing to pivot in response to changes and to collect data where and when you can. Our original research plan incorporated two major research questions: one focused on the independent variable of federal disaster response aid in dollars and the other focused on another form of disaster response and recovery resources, non-profit organizations, and specifically exploring the impact of their growth post-disaster employing a categorized count of organizations as the independent variable. Upon determining that matching the data sources of the study we were replicating Puerto Rico was, for some sources, impossible or would delay, and threaten, our ability to generate results in time, we decided to refocus our research design on disaster response aid with data that was already available. That quick and flexible pivot allowed us to complete the project within the specified timeframe, revealing useful findings and making disaster aid distribution recommendations for improved economic equality and health equity.Participation was enhanced because we had local research assistants and a variety of ways, in-person, via telephone, or online, to collaborate with data collection. Research team members and study participants were all balancing their own path to recovery, navigating the impacts of compound crises. So long as project tasks could fit into their individual balancing act, they could ensure they contributed to advancing the project goals. As soon as the calendar of work grew in intensity, was limited by time and space, it lost flexibility and participation suffered.We found that collecting and analyzing data iteratively and engaging local resources can enable rapid research that is rigorous and yields rich data. Our timeline did not allow us to collect all our primary data, analyze it all together, and then interpret it in a linear fashion. Neither were we able to convene and train an analysis team to follow a step-by-step process of transcribing, reading, defining codes, re-reading, re-defining codes, coding, grouping into themes, applying themes back to the text, identifying patterns, trends and connections between themes, and interpreting themes to apply meaning within the specific context of our research, in a linear way. Instead, we recruited community members to participate in data collection and analysis in an iterative way whereby data were collected, analyzed, and interpreted by people who were steeped in the context within which our research was situated. In this manner, we were able to leverage both the overlap of people's lived experience with the focused data and the overlap of each step with the other to extract deep and rich meaning from the primary qualitative data gathered, analyzed and interpreted in a very short timeframe. Finally, we also combined two separate objectives into one final set of activities: (1) to return findings to the communities where we collected data and (2) to engage local stakeholders in checking data, interpreting findings and discussing potential recommendations. This enabled us to stay aligned with our values as a research team around ensuring that people who contribute to data have access to the knowledge that is created using it, while also honoring the importance of member checking in qualitative research and leveraging the lived experience of community members and leaders in the translation of findings to potential recommendations for positive change.Sharing data and preliminary analysis with stakeholders enabled more people to make better informed decisions along the way, within their timeframes. Initial letters and meetings with municipal employees about the concern motivating the research led to more active participation in the town hall meeting at one of the research sites. Individuals at the town hall meetings referenced past neighborhood structures and arrived at a consensus around the need to revitalize community level organizations to improve post-disaster recovery and risk mitigation efforts.Though it is difficult to know what benefit was gained by FEMA from our response to their online call for recommendations, it undoubtedly contributed to the chorus of voices clamoring for improved equity considerations in the US federal disaster response and recovery activities. FEMA demonstrated a deepened focus on equity in their efforts as Goal #1 (of three) of the 2022–2026 Strategic Plan (published in December 2021) is: “Instill Equity as a Foundation of Emergency Management.”As much of the literature we reviewed focused on rapid qualitative methods, we begin with some recommendations for rapid quantitative research. First, we recognize that even when using secondary data, data collection within a rapid research timeline can be challenging and such challenges must be planned for, with contingencies, to maintain the shortened timeframe. Once data are obtained, it can be helpful to envision how the data should be structured for most efficient analyses: cross section (multiple variables at a point in time), time series (a single variable at multiple points in time), or panel data/longitudinal (multiple variables at multiple time periods). Each structure brings its own set of challenges. As we brought multiple identification strategies into our models from different sources, the key challenge was determining whether the variables we had access to addressed the research questions clearly and if we used the proper econometric approach.Designing a data dictionary may feel unnecessarily time-consuming, yet for our team it was essential and saved us time in intra-team communications. Your data dictionary table should include: all the links where the data were found, the date they were originally accessed, a description of each variable, why you chose that variable (whether or not there was a need to use proxies) and selected literature on the use of that variable, and their expected sign. There are three data structures: cross-section, panel data/longitudinal, and time-series. Data structure is key for your regression models to be estimated properly. If data is not arranged properly, your software may not be able to estimate the model  framework for rapid research, and borrows from and combines elements of the impoverishment risks and returns and the sustainable livelihoods approaches to quickly measure changes in livelihoods across five elements . It was developed by Kabra  for use Like our study, the framework uses mixed methods and engages with those who are impacted in a participatory way, though neither reach the standard of Community-Based Participatory Research where participants are engaged in research design decisions (Udoh et al., For example, other research teams have found across multiple contexts that, “Households with poor social networks suffered livelihood setbacks which many of them have not been able to recover from, leading to emergence of sharp social and economic differentiation in the post-relocation period” (Chopel et al., This body of scholarship, and adaptation of similar methodologies, can also help to extend our understanding of the longer-term impacts on poverty and economic inequality that our research pointed to in the more immediate recovery period. For example, Kabra  found thReflecting upon rapid dissemination activities, we find that the early sharing of data and findings, did engender expressions of ownership of the data and public expressions of how to apply it. Municipal staff and residents to recognized the importance of strengthening social networks to improve readiness, response, and recovery at the local level. The lively exchange during and after the policy seminar is another example of collaborators engaging with knowledge being discussed.Local partnerships at recovery sites are best to lead rapid response, research, and dissemination, and have the potential to enable rapid learning and quality improvement in disaster recovery. As discussed in the limitations, members of the research team identified bureaucratic barriers with the potential to systemically exclude local partnerships. To minimize this potential, we recommend for federal agencies identify segments of the operational budget for local contracting. This is already done for post-disaster debris removal, construction or field personnel, but could be done for training and evaluation services as well. Strategically designed pilot programs or calls for proposals can be developed to foster local collaborations in the generation of knowledge allowing agencies to rapidly respond to different disaster contexts and key regional differences. This practice has already demonstrated success when used by the Natural Hazard Center, the National Science Foundation, the Center for Disease Control and the Environmental Protection Agency. Such a proactive engagement with local scientists and organizations has the added benefit of contributing to decolonizing recovery efforts and disaster-informed science. A similar recommendation is raised within the original research that suggest inequitable impacts of current aid distribution patterns could be reduced if federal agencies were able to pilot new distribution or engagement strategies to respond to the rapidly changing post-disaster context.Inclusive practices need to be designed to address the value-chain of knowledge generation, from research design to public dissemination. Alternatives for meaningful authorship and credit should be defined and be subject to review. Changing protocols within a rapid timeline is perhaps easier early on, but gets increasingly more challenging as due dates appear on the horizon. In the initial report, after noting that the original path to authorship had not rendered anticipated results, contributorship was used as the default mechanism for inclusion of all collaborators. Intent on corroborating initial assessment of why and how participation tapered off in the final stages of the rapid research, the Co-PIs invited the field research team to review and discuss the reflections in this chapter. Outside of rapid schedule deadlines, the present reflection benefited from tasks and responsibilities defined with added mindfulness to competing schedules. Flexibility aided inclusive authorship.In our changing world, where disasters last longer and are more frequent, making almost all natural hazards that hit unprepared human settlements result in compounding or cascading disasters, rapid research is becoming more and more important. As Kyrkjebo et al.  argue inGiven that our research illuminated some unintended negative consequences of public disaster response aid, the disaster research community should also apply rapid research methodologies toward the support of the business community as crucial actors both before and after natural disasters. Saleem et al.  have devpredatory delay. He defined it as “the blocking or slowing of needed change, in order to make money off unsustainable, unjust systems in the meantime.” The “in order to,” or the connection between the money being made from unsustainable or unjust systems may not be as clear as it is phrased here. What is clear, however, is that in a post-disaster context, delay kills people, and it kills poor and working class people more, and more quickly. This connection was demonstrated by several studies of the contended number of excess deaths that could be attributed to Hurricane Maria specifically within Puerto Rico (Cowan, Rapid research creates opportunities to make data-informed program and policy adjustments when they can be most impactful. In our use of rapid research methodologies, our goal was to generate knowledge about relationships that impacted disaster recovery in order to facilitate change in institutional aid disbursement policies. We used combined recruiting of local collaborators in data collection and analysis, with community-level dissemination. The early and iterative dissemination grew trustworthiness in our findings and enabled us to hone findings further before presenting to policy makers and media. Our mixed method findings demonstrated that, in the case of Puerto Rico, unless equity is conscientiously aimed for, aid is likely to follow existing, worn paths of power, privilege, and marginalization to amplify existing inequities rather than creating new paths for improved equity and a just recovery. Alex Steffen, a futurist particularly concerned with climate change and disasters, coined the term o Cowan, .predatory in Puerto Rico. Willison et al. (A quick glance at the amount and pace of aid sent to Texas and Florida, in comparison to the amount and pace of aid sent to Puerto Rico, and juxtaposed with the number of injuries and deaths experienced in these places during the same time period, makes clear that delay was, and continues to be, n et al.  found thn et al. . The chanot only in terms of severity of the disaster but also accounting for preexisting population vulnerabilities created by a system that marginalizes poor and working-class communities, and communities of color. We are convinced that rapid research can and will inform that strategy, making it more specific and more effective in its design and implementation.Our team believes that rapid research has the potential to contribute to reducing predatory delay and bring attention to mechanisms that reproduce systemic racio-colonial inequities. Our quantitative findings identified a pattern that we see globally, both in the Global North (Smiley et al., Both the media and policy makers pay closer attention to research on current events. Hence, our recommendations are to fund and support more rapid research and to work early and iteratively to enable more stakeholders to engage in the process. The more rapid research and rapid dissemination we do, the better we will get at it, and the more accustomed community leaders, policy makers and program designers will become to using data to inform their decisions. Rapid research can be an important tool to correct economic inequality and improve the lives of people forced to live on the margins of our society.lgorbea@prpassworkshop.org.The data analyzed in this study is subject to the following licenses/restrictions: available upon request to corresponding authors. Requests to access these datasets should be directed to The studies involving human participants were reviewed and approved by Ethical and Independent Review Services. The patients/participants provided their written informed consent to participate in this study.LG, ACh, and AF were the co-principal investigators that proposed and were responsible for completing the research project. ACh designed the study, ensured that the methodology fit the theoretical framework, advised on data collection and analysis, and led the development of the initial draft of the manuscript. LG brought the teams together, led the primary qualitative data collection and analysis, and collaborated in the writing of initial draft and led the final revision process. AF led the quantitative modeling and gathering of secondary data. LB, GR, NP, ACa, JM, LL, and PS were members of the research team led by LG that assisted in gathering data, joined in the reflection of the methodology and provided a critical review of the manuscript.