Reflections From the Field: Using Ethical Reflexivity in a Quantitative Study

Abstract

Micro-ethics provides a framework for researchers to identify the everyday moral, ethical, and often unpredictable moments that arise through research (Spiel et al., 2020). Primarily associated with qualitative traditions, the application of micro-ethics in quantitative survey-based research remains underexplored. In this article, we reflect on the role of micro-ethics in SuperMIX, a longitudinal epidemiological cohort study involving people who use drugs in Victoria, Australia. Drawing on interview notes, meeting minutes, and team reflections, we provide examples of how we attend to micro-ethical moments through a practice of ethical reflexivity. Using Tracy’s (2010) ethical domains of situational and relational ethics, we present reflections across four themes: (1) blurring boundaries, (2) co-constituting research, (3) prioritising relationships, and (4) enacting care. We illustrate how an ethically reflexive practice has enabled us to attend to the autonomy, safety, and dignity of participants. Our reflections highlight the value of acknowledging and embracing the inescapable subjectivity of researchers in quantitative work, showing how this approach can lead to meaningful engagement, enhance rigour, and challenge researcher-participant power dynamics. By sharing these field-based insights, we hope to contribute to broader interdisciplinary conversations about ethics, care and the evolving role of researchers working with priority populations.

Introduction

During our fieldwork ¹ on SuperMIX, an epidemiological study with people who use drugs, we frequently make complex ethical decisions that more often resemble those explored in qualitative research. These encounters have led us to draw upon the concept of micro-ethics. Micro-ethics in research considers the everyday, ethically charged moments that must be attended to, but which are not addressed by ethics applications (procedural ethics) (Guillemin & Gillam, 2004; Spiel et al., 2020). While micro-ethics provides a framework to recognise ethical situations as they arise, ethical reflexivity provides the means by which to respond (Spiel et al., 2020). At present, there are limited examples of the application of micro-ethics and ethical reflexivity in quantitative survey-based research ² .

In this article, we reflect on our experiences working with people who use drugs in Melbourne, Australia. Our cohort, like those in much of the world, continue to experience disproportionate health burdens, including infectious diseases, incarceration and housing instability (Degenhardt et al., 2023; Van Den Boom et al., 2022). These inequities are compounded by legacies of stigma and discrimination, which are manifest in both public attitudes and institutional responses, including health and public policies (Addison et al., 2022; Broady et al., 2024; Griffin et al., 2025). These issues, as well as, experiences of insecurity, harassment and social exclusion (Dertadian & Tomsen, 2022) underpin the objectives of SuperMIX and inform our daily engagement with participants as researchers.

Drawing upon interview notes, meeting minutes and team reflections, our reflections are presented under Tracy’s (2010) ethical domains: situational ethics and ethical relationships. They include: (1) blurring boundaries; (2) co-constituting research; (3) prioritising relationships; and (4) enacting care. Our reflections illustrate how engaging in a reflexive practice, not typically considered in quantitative work, enhances outcomes for both participants and researchers. We offer these reflections as a contribution to ongoing interdisciplinary conversations about ethics, care, and rigour in research with priority populations.

Background: Micro-ethics and Ethical Reflexivity

Ethical frameworks aim to provide a structure for anticipating and mitigating risks, ensuring research is rigorous, respectful, beneficial to participants, and conducted by competent researchers (National Statement on Ethical Conduct in Human Research, 2023). In medical research, procedural ethics, the process of gaining approval for research studies, is underpinned by principlism, the dominant paradigm of biomedical ethics (Beauchamp & Childress, 2019; Reid et al., 2018). Introduced in the late 1970s, principlism comprises four philosophical principles that endure today: beneficence (do good), non-maleficence (do no harm), respect for autonomy (self-determination), and justice (treat fairly) (Beauchamp & Childress, 2019; Reid et al., 2018). While a worthwhile framework for procedural ethics, principlism’s utility has been critiqued for encouraging adherence to the ‘letter’ rather than the ‘spirit’ of these principles, thereby limiting its scope and value (Hammersley, 2015; Reid et al., 2018). To address these limitations, Guillemin and Gillam (2004) make a distinction between procedural ethics (ethical approval) and process ethics, that is, ethics that unfolds as part of research, which we refer to as micro-ethics.

The term micro-ethics was developed in clinical practice by Komesaroff (1995) to describe the disconnect between bioethics and the everyday ethical negotiations that occur between doctor and patient (Guillemin & Gillam, 2004). As Schürer and Jensen (2022) explain, Komesaroff's (1995) micro-ethics aimed to conceptualise the negotiation of responses, decisions and relationships that exist in all interactions between humans and extend these ideas to the researcher-participant relationship. From this perspective, ethics is not a one-off approval but an ongoing, situated practice (Guillemin & Gillam, 2004; Reid et al., 2018). In Participatory Action Research, for example, where participants are partners in an iterative and ongoing process, micro-ethics provides a framework for incorporating their voices and shaping research as it is being produced (Brown et al., 2024; Spiel et al., 2020). This approach requires researchers to exercise a high degree of reflexivity so that they may remain aware of their positionality and the assumptions that inform their behaviour, as well as the evolving ethical landscape in which they play an active role in producing (Guillemin & Gillam, 2004; Reid et al., 2018; Schürer & Jensen, 2022).

‘Reflexivity' can mean many things (Lynch, 2000; von Unger, 2021) and is often ‘hard to pin down’ (Ide & Beddoe, 2024, p.725). Methodologically, it refers to an analytical practice for researchers to consider and account for the influence they have on their investigation and its results (von Unger, 2021). Here, we draw on von Unger’s (2021) concept of ethical reflexivity, which serves both analytical and ethical purposes. Ethical reflexivity urges the researcher to consider the study’s implications for participants, as well as the broader political and social context within which the research is embedded (von Unger, 2021). In our practice, we have adopted ethical reflexivity to respond to micro-ethical moments as they occur in research. Although seldom promoted for use in quantitative research, we have found ethical reflexivity to be a generative tool for attending to the complex relationships that are developed between researchers and participants during data collection and sustained over time. In essence, being ethically reflexive has been about “doing the right thing”, which is different for each fieldworker, contingent on our own experiences and beliefs, and which may be informed by ethical concepts from principlism to care ethics (Reid et al., 2018; Smyth & Shacklock, 1998). To frame how ethical reflexivity is applied in the field, and guide our thinking, we draw on Tracy’s (2010) ethical domains.

Tracy’s (2010) four ethical domains build on Guillemin and Gillam’s (2004) micro-ethics and comprise: procedural ethics, situational ethics, ethical relationships and ethical issues in exiting the study (Reid et al., 2018). Reid and colleagues (2018) used Tracy’s domains to frame their findings; here, we take a similar approach, focusing on only two domains: situational ethics and ethical relationships, as these are the domains from which we, as researchers in the field, can provide insight. In the following, we provide an empirical reflection on how micro-ethics informs our practice and how applying ethical reflexivity helps us respond to ethically important moments as they arise (Guillemin & Gillam, 2004).

The SuperMIX Study and Fieldwork

Longitudinal cohort studies such as SuperMIX are an effective tool for understanding the health, behavioural, and social trajectories of people who inject drugs (Berryman et al., 2024; Rudolph et al., 2023; Sergeant et al., 2024; van Santen et al., 2023). The Melbourne injecting drug use cohort study (SuperMIX) was established in Melbourne, Australia in 2008 and recruits people who report injecting drug use at least monthly for the past six months, reside in Melbourne or Greater Geelong, and were able to provide informed consent at the time of interview (Horyniak et al., 2013; Van Den Boom et al., 2022). Participants are recruited using a combination of respondent-driven sampling, snowball sampling and outreach methods.

Data are collected annually via a researcher-administered quantitative survey either in-person (preferred and most common) or over the phone. Survey domains include participant demographics, social circumstances, physical and mental health, drug use, and engagement with health and criminal justice systems. Interviews take approximately 45-60 minutes to complete. We also get consent from participants to link their data with several state and national mortality, health and criminal legal administrative datasets. Venous blood samples are collected by researchers and tested for hepatitis B, hepatitis C, and HIV. Since January 2025, pulmonary (lung) function has been assessed using spirometry. Participants are followed assertively regarding their results, and referrals for care are provided when needed. Participants are compensated for their time and expertise with cash payments (currently between 40–60AUD), aligning with standard practice in alcohol and other drug (AOD) research in Australia (Winter et al., 2022).

The duration of the SuperMIX study, the number of participants (more than 2,000 at July 2025), and the breadth of quantitative data collected have provided other opportunities to explore the individual, public health, and social implications of injecting drug use in Victoria. Topics have included the impact of COVID-19 on access to harm reduction (Efunnuga et al., 2022), cocktail drug use and injecting (Palmer et al., 2020), and the impact of unstable housing on hepatitis C (McColl et al., 2024). Findings from SuperMIX have influenced public policy, including the decision to establish (and then make permanent) Melbourne’s first supervised injecting room (Department of Health and Human Services, 2020).

A team of chief investigators oversee SuperMIX, while field-based researchers manage the day-to-day operations of the study, including conducting interviews and recruiting participants. Recruitment occurs at key locations, including prominent street-based drug markets and health and harm reduction services. To make participation as accessible as possible, interviews are conducted from a mobile study van or, when suitable, from other public spaces such as park benches, carparks, or curbsides. The adaptability and mobility of field-based researchers are essential for effectively recruiting and following up with participants. In these sometimes unpredictable settings, creating a safe and comfortable space relies on the connections forged between researchers and participants, as much as the physical environment.

Participant safety and researcher wellbeing are interdependent; training and orientation are essential for sustaining this balance both in and out of the field. Orientation includes study induction, shadowing senior colleagues, and foundational education in harm reduction, AOD services, and blood-borne viruses. Researchers must obtain certification in Good Clinical Practice, Community Overdose Prevention Training (COPE), and phlebotomy, and complete cultural safety and LGBTQ + inclusion training. Additional professional development opportunities include First Aid and CPR, Mental Health First Aid and de-escalation training, which are offered on an ongoing basis. Finally, researchers have access to Employee Assistance Program (EAP) services, including counselling as well as regular supervision, group reflection sessions and ad-hoc debriefing.

In addition to the training and orientation provided, SuperMIX utilises a Standard Operating Protocol (SOP), which outlines procedures for safe engagement and ways to respond to challenging events. The SOP is an acknowledgment that working and researching in the illicit drug space continues to have legal, ethical, social and safety complexities for both participants and researchers (Coupland & Maher, 2005; Higgs et al., 2006; Paterson & Panessa, 2008; Walker et al., 2022). While it is a valuable tool, our field-based researchers are often called to respond to complex situations that require intuition and empathy beyond what is possible to foresee and document in a protocol. Below, we discuss the reality of SuperMIX from the perspective of the field-based research team (referred to as researchers) and explore how it necessitates micro-ethical, nuanced decision-making and ongoing reflection.

Sources of Reflections

Several data sources were used to inform our reflections, including interview notes (collected via REDCap, a data collection and management software (Harris et al., 2019)), discussions with researchers and minutes from regular meetings. After each survey, researchers are encouraged to add a free-text interview note; they are not part of the survey per se but are added at the researcher’s discretion, capturing details regarding engagement and the interview itself. Interview notes provide depth and context to participants’ experiences, offering insight into their physical and emotional wellbeing, as well as their circumstances. They provide practical information about the interview, so researchers conducting follow-up interviews, who may differ from year to year, have insight to support their engagement. They may, for example, include information about a successful blood draw location, service referral pathways and potentially difficult or painful topics for the participant. The interview notes promote continuity, which helps to develop a richer understanding of participants’ lives, build rapport, and support more informed, personalised, and empathetic engagement over time. As such, interview notes provide a rich source of data for this paper. Minutes from our weekly meetings with the research team have also informed this paper – especially relevant here are discussions about complex conversations with participants and how these were handled. These sources of reflection offer insight into the ethical, emotional, and practical dimensions of our research.

Reflections

Reflections are presented under two of Tracy’s (2010) four ethical domains: situational ethics and relational ethics (Tracy, 2010) ³ . Two themes are presented under each domain. For situational ethics, themes include blurring boundaries and co-constituting research. For relational ethics, themes include prioritising relationships and enacting care through research. Each theme addresses common micro-ethical moments encountered by SuperMIX researchers that require ethical reflexivity. The implications of these reflections are explored in the discussion.

Situational Ethics

Situational ethics refers to ‘ethical practices that emerge from a reasoned consideration of a context’s specific circumstances’ (Tracy, 2010, p. 847). Tracy (2010) posits that ethical actions not only emerge from prescribed laws, but also from context and reason, and that ethical decisions should be based on the circumstances of a given situation. Situational ethics deals with ‘the unpredictable, often subtle, yet ethically important moments that come up in the field’ (Ellis, 2007, p. 4). We attend to situational ethics in our role as researchers by blurring boundaries, as well as by implementing ways to co-constitute research.

Blurring Boundaries

This theme demonstrates ethical reflexivity in the context of situational ethics, as we provide referrals and offer support to participants in ways that fall outside the scope of our procedural ethics and standard operating procedures. While referrals, such as those for mental health support after self-harm disclosures or for treatment following a blood-borne virus diagnosis are covered in SuperMIX’s procedural ethics, researchers often go “above and beyond” the scope of what is formally required. In doing so, we may “blur the boundaries” between researchers and service providers. Navigating these dual roles raises important questions about our assumed neutrality, particularly as researchers in a quantitative study. The following interview note illustrates this complexity. In it, the participant calls upon the support of the researcher to discuss their desire to stop using heroin, which had come up during their interview the previous week.

[Participant] came past the van whilst his partner was being interviewed. Follow up conversation from interview last week about his use - [participant] reiterated he is wanting to stop using, is on LAIB [long acting injectable buprenorphine] but he is able to use on top/feel [the effects of heroin]. [Researcher] and [participant] chatted about social and lifestyle triggers for use. Boredom being one – [researcher] referred [participant] to the [local] Men's Shed. (Interview note 1).

Here, the researcher provides a referral outside of the formal interview context, reflecting Tracy’s (2010) position that situational ethics requires our responsibilities in the field to extend beyond those covered by review boards (Tracy, 2010).

Providing support to participants can come in many and varied forms. Another example is in the following interview note, which recounts when a researcher supported a participant to attend their court hearing.

Attended County Court today with [participant]. It was likely to end with a prison sentence but both the barrister and the participant really appreciated the support we were able to provide both in Court and with the support letter accompanying them...Participant told the presiding judge that we were more than just workers, they felt like we were actual friends (Interview note 2).

Supporting a participant to attend court falls well outside conventional research roles and requires significant consideration. Ultimately, this decision was deemed appropriate given the circumstances and the nature of the relationship between the participant and researcher. Our position is that by choosing to attend court and provide a letter of support, the researcher employed a reflexive ethic of care that embodies Tracy's (2010) situational ethics. We have found that blurring traditional researcher-participant roles also helps to build trust and rapport. In turn, this improves study engagement and strengthens our reputation within the community, supporting the continuity of SuperMIX as a longitudinal cohort study.

Co-constituting Research

Within this theme, we examine how micro-ethical moments arise when participant responses prompt a revaluation of our research tools and questions. Employing ethical reflexivity has enabled us to exercise our capacity to co-constitute research in response to participants’ insights and to advocate for changes based on their lived experience. An example of this was when participants’ responses reshaped trauma-related questions that had been recently added to the survey. The trauma questions were introduced to determine whether participants had experienced a traumatic event, and if so, prompted several follow-up questions exploring its impact. While the initial question did not require researchers to probe for details, participants often felt compelled to share their story or provide context. Regardless of their interpretation of the question, it almost always resulted in participants resurfacing a traumatic event, often one they had worked hard to suppress. The interview notes below provide examples of this.

[Participant] initially eager for the interview to be quick, however once in the swing of it, P was attentive and calm. Trauma questions were skipped as P had some difficulty comprehending the Qs and then stated he felt triggered. (Interview note 3).

[Participant] friendly and alert. a little anxious. currently sleeping rough, injecting heroin and ice 2-5 times a day based on access. skipped trauma questions as P didnt feel like “getting into it”. (Interview note 4).

In the examples above, ethical reflexivity was employed to make a subjective assessment about whether the potential benefits of the research outweighed the possible harm to the participant. Although an ethics board approved these questions, after implementing them in the field, researchers ultimately determined that the potential for harm outweighed any anticipated benefits. As a result, field researchers advocated for an abridged set of questions, which has now been implemented.

In situational ethics, Tracy (2010) encourages researchers to constantly reflect on whether the harms of the research practice outweigh its moral goals. In the preceding examples, ethical reflexivity prompted a reassessment of how sensitive topics are approached in a way that balances research objectives with participant wellbeing.

Relational Ethics

Relational ethics is linked to an ethic of care that values mutual respect, dignity and connectedness between researchers, participants and communities (Ellis, 2007; Tracy, 2010). Relationally ethical researchers are mindful of how their character and actions in the field have consequences for their participants. They engage in reciprocity and are concerned with human flourishing (Tracy, 2010). We have found that prioritising relationships and enacting care have enabled us to attend to relational, micro-ethical moments in the field.

Prioritising Relationships

This theme examines how researchers will prioritise relationships with participants over conformity to the survey. We understand these moments in the context of Tracy’s (2010) relational ethics, as our engagement is concerned with the flourishing of participants. Often, this involves responding to difficult disclosures, which requires balancing participants’ values, researcher safety and appropriate risk-taking. This is exemplified by navigating the survey in a way that allows participants to ‘define the rules of the research’ (Tracy, 2010, p. 847). As shown in the following interview note, this occurred when a researcher decided to skip survey questions related to mental and physical health due to the participant’s mental state and reluctance to talk about his health.

[Participant] disclosed persistent suicidality of late. [Participant] has not disclosed this to his GP and does not want to seek specialist [mental health] support at this time. [Participant] confirmed that he has confided to his friend about his [mental health]. This friend gave him a ride to the van and is a support to [him]. [Mental health] and Physical health sections [of survey] not completed with [Participant] today due to current mental state and reluctance to talk about his health. [Participant] agreed with this decision. (Interview note 5).

Here, being ethically reflexive involved weighing the benefits of data collection against the participant’s emotional state. Ultimately, establishing rapport and ensuring comfort was mutually prioritised over rigid consistency in survey delivery.

For participants who may lack clear and robust psychological support structures, disclosing traumatic events can lead to lasting emotional distress. For researchers, repeated exposure to such narratives can lead to vicarious trauma, affecting their well-being and professional sustainability. To manage disclosures, we have found the use of protective interruption, a strategy that gently stymies disclosures while reaffirming trust and safety, is sometimes vital to maintaining boundaries and safeguarding both parties. This is exemplified in the interview note below, where, as opposed to skipping survey questions as exemplified in Interview Note 5, the researcher redirected the participant back to the survey.

[Participant] was easily distracted and tangential in conversation, predominantly recounting scenes and situations of a violent nature in graphic detail. Writer had to interject a number of times in an attempt to ground and reorient [Participant] to present time and remind him of the survey. (Interview note 6).

There is no one-size-fits-all approach for researchers to respond to these disclosures, and no standard operating procedure can outline the numerous, nuanced and human responses that are necessary. In these moments, researchers must navigate the emotional labour involved by setting appropriate boundaries, while also ensuring participants are respected, valued, and have autonomy over how they engage with the research.

Enacting Care

In this theme, we examine how micro-ethical tensions are embedded in our dual role of researchers as data collectors and providers of health and harm reduction services. Navigating these responsibilities requires upholding participants’ agency while also ensuring safety. This is particularly evident when it comes to venipuncture, which produces ethical dilemmas related to stigma, practical dilemmas related to discomfort, and medical risks such as needle-stick injuries.

People who inject drugs for prolonged periods can experience venous damage, which sometimes makes phlebotomy difficult and distressing. As a result, they may forgo care out of fear that attempts will affect their venous access, be painful, fail or that they will experience stigma from health professionals (Aung et al., 2023; Clements et al., 2015). This is true of many participants in SuperMIX. In response, we support participants with difficult intravenous access to perform their own blood test in a supportive and controlled environment. Participants often express their appreciation for this, as exemplified in the following interview note.

[Participant] reported experiencing a lot of stigma from general public and health professionals due to their drug use. [Participant] was grateful for being able to have a non-judgmental discussion about their health and drug use and for being able to take their own bloods. (Interview note 7).

Here, being ethically reflexive involved weighing infection control, autonomy and the participant’s comfort. Aligning with the tenets of relational ethics, in these exchanges, we value mutual respect and dignity by acknowledging participants as experts of their bodies. In turn, this often leads to more positive engagement and successful blood draws.

Many participants, particularly those without a phone or fixed address, see the study as one of their few opportunities to engage with a health service. While we have found this dual role to be an effective health intervention, it also introduces a range of micro-ethical considerations. Our responsibilities are further complicated by our registration as a Needle and Syringe Program (NSP), through which we distribute sterile injecting equipment and naloxone (a medication that reverses an opioid overdose). We must be mindful of how we manage expectations regarding the type and scope of care we can provide, as well as how our presence and relationships influence consent, disclosures, and engagement.

Discussion

Our reflections offer insight into how micro-ethics emerge and how ethical reflexivity is commonly employed during data collection in the research we conduct with SuperMIX participants. Many of the approaches described, such as facilitated blood collection and outreach, are not new to health or research (Griffin et al., 2025; Stewart et al., 2021; Winter et al., 2008). We do not present our approaches as new, but rather as having a novel application in this context. We aim to demonstrate how relational and responsive practices have been embedded in our study to support participants and improve data collection in meaningful ways. We hope our reflections may be relevant not only to researchers working with people who inject drugs but also to researchers and health professionals working with other priority populations. We propose that these practices can be understood through a framework of micro-ethics and attended to by employing ethical reflexivity.

This article presents empirical reflections that draw upon interview notes, which describe our subjective experiences as researchers. Thus, we recognise, and have tried to embrace, how our worldviews inherently shape our discussion. We also acknowledge that our reflections do not directly represent the views of participants; however, we note that they align with previous research that describes the perspectives and experiences of SuperMIX participants (see Berryman et al., 2024).

Our reflections on prioritising relationships particularly reflect a growing body of critical social science literature that explores how ‘different socio-material relations of care produce different capacities for service delivery’ (Dertadian & Yates, 2023, p. 136). Dertadian and Yates (2023) explore how staff in the Sydney supervised injecting room deploy a ‘politics of care’ (p.144) when responding to overdose. They explain how staff’s approach not only relies on a medicalised model but also considers a range of individual factors, such as whether someone has recently been released from prison or is ‘not themselves’ (p.145). This approach depends on staff developing an intimate, relational understanding of their clients that extends beyond an apolitical, clinical framework. Similarly, our study adopts a model of care that moves beyond an objective and detached stance often associated with quantitative research. The ways we build and maintain relationships with participants, for example, involve engaging in conversations that fall outside the formal scope of our study. In these moments, ethical reflexivity is employed to make situational judgments about when to continue a conversation (by providing referrals) or respectfully step back (by skipping survey questions).

Viewing our study through a micro-ethical framework and employing ethical reflexivity has also helped us recognise and respond to the emotional toll that we, as researchers, experience. As exemplified in our reflections, researchers are regularly privy to intimate details of participants’ lives. While it is a privilege to bear witness to participants’ stories of resilience and perseverance, it is also often emotionally challenging. Responding to disclosures of abuse, self-harm, stigma, and discrimination can take a significant toll on both participants and researchers and this is further complicated by the unique bonds that can develop between participants and researchers. Ethical reflexivity offers a means to make sense of and respond to emotionally complex conversations by critically examining them as a social processes that have consequences beyond research outputs (von Unger, 2021). We operationalise ethical reflexivity in the field through protective interruption, and outside the field, through regular team meetings and debriefs. Furthermore, we foster a culture that acknowledges and validates the emotional labour involved in this type of research for both participants and researchers.

The benefit of ethical reflexivity is further highlighted through adjusting and updating the interview in response to participants’ emotional states, such as by omitting questions that could cause distress. We have found that this not only enhances participants’ experience with the research but also strengthens the rigour of the study. While omitting questions may seem contrary to improving rigour, adapting instruments based on participants’ feedback or recurring challenges ensures tools remain relevant and sensitive to their realities. Discussions with participants have shaped new research directions on topics, including for example, oral health (Abdelsalam et al., 2023), and the disproportionate burden participants experienced from the COVID-19 pandemic (Walker et al., 2023, 2025). In this way, participants are not only passive subjects but active participants in the research and co-producers of knowledge. We argue that, although this approach is often associated with qualitative methods, it has proven valuable in our quantitative work, provided we have remained open to it.

Providing support and referrals offers one of the clearest examples of enacting care through ethical reflexivity. As demonstrated in Interview note 1, in which a participant disclosed boredom as a trigger, the researcher engaged further and was able to provide a referral to a relevant support service. Interview notes also capture the inverse dynamic, in which participants actively seek support from researchers. These everyday interactions in the field reflect how the study’s broader aims, to understand and improve the health and social trajectories of people who inject drugs, are realised not only through data collection and study outputs but through our engagement in the field. Berryman et al. (2024) refer to these moments as ‘acts of advocacy’ (p. 233) and, similarly to us, found that providing support and referrals was of critical importance to SuperMIX researchers.

Being ethically reflexive has led us to consider how operating as a health service embroils us within systems that have discriminated against, stigmatised, and harmed people who use illicit drugs (Broady et al., 2024; Couto E Cruz et al., 2019). Our approach is informed by the understanding that participants may be hesitant to engage with us due to reasonable fear and distrust, and that is something we must actively reckon with. When conducting phlebotomy, for example, we have found that enabling participants with poor venous access the opportunity to take their own blood helps turn what can be a stressful or potentially disempowering experience into one of autonomy and trust. This small act of flexibility signals to participants that their agency and expertise over their own bodies are valued. Further, this flexibility enables knowledge to be mutually exchanged. We operate under the sentiment that participants are the experts of their own bodies and veins. Thus, we argue that participant-led phlebotomy in the SuperMIX study actively contests traditional power dynamics of clinician-patient interactions; however, we acknowledge that it does not eliminate it entirely. While there is still significant work to be done in this space, we believe these practices represent a small but meaningful step forward, and being ethically reflexive will enable us to remain attentive to shifts over time.

The National Statement on Ethical Issues for Research Involving Injecting Drug Users by the Australian Injecting & Illicit Drug Users League (2002) notes that people who use drugs have felt ‘over-researched’, ‘unclear about the objectives of the research’, and angry at never hearing back about findings or at the inconsistent approaches taken to compensation (p.9). Here, we pay special attention to Aboriginal and Torres Strait Islander participants whose harms are compounded by colonisation and systemic racism (Goodman et al., 2018; Jaworsky, 2019; Tuhiwai-Smith, 2012). We understand that these legacies must be addressed not only through our procedural ethics framework and research outputs, but also in the day-to-day micro-ethical interactions we have with participants.

AIVL’s Statement calls for changes to the way research with illicit drug users is conceptualised, used and practised (AIVL, 2002). We hope that the way participants’ feedback has shaped SuperMIX’s content goes some way to addressing this. By adopting ethical reflexivity in our quantitative study, we have sought to redress power imbalances by creating opportunities for participants to shape the study’s content to better reflect their priorities. There are still improvements that can be made within the SuperMIX study based on AIVL's (2002) guidelines, including, for example, more regular sharing of findings. We see ethical reflexivity as an ongoing, iterative and social process that helps us contextualise our work, critically examine our practices, and strengthen what is working well. By sharing our experiences, we aim to contribute to a broader dialogue about ethical research with priority populations, particularly in public health settings.

Conclusion

Through a micro-ethical framework, we have illustrated how navigating disclosures, adjusting research tools, and enacting care have shaped our engagement with participants and the direction of the SuperMIX study. Overall, we believe the broader aims of research should not only be realised through research outputs but also embodied in everyday interactions with participants. Through ethical reflexivity, we have been able to recognise how our positionality, actions, and judgments actively mediate participants’ experiences and engagement with the study, thereby improving research outputs. As researchers, we have long found ourselves instinctively “doing the right thing” beyond the scope of procedural ethics. In many ways, this has meant treating ethics as an iterative, ongoing and social process (von Unger, 2021). Retrospectively, we have conceptualised these practices through the lens of micro-ethics and ethical reflexivity with the hope that these frameworks may be adopted across different contexts and priority populations. By adopting these approaches, we aim to challenge the assumption that quantitative research must remain detached and impersonal to achieve rigour. In our reality, we have found that embracing subjectivity within quantitative research can foster deeper engagement, generate richer outputs and enhance the experiences of both participants and researchers in small but meaningful ways.