Large, collaborative research programs at the intersection of agriculture, nutrition, and health (ANH) often involve human participants and necessitate ethical oversight. Due to the complexity of these studies, ethical challenges may arise not only before fieldwork but throughout the research process, requiring flexible, embedded mechanisms to detect, assess, and manage ethical issues in real time. Drawing on the concept of ‘ethics in practice,’ this study introduces a novel “real-time research ethics approach” (RTREA) designed to integrate ethical reflection into research activities, fostering continuous dialogue between researchers and participants. This approach aims to enhance responsiveness to ethical concerns and improve participant experience, potentially supporting adherence and retention. In this case study, a bioethics team (BT) was embedded in a community-based randomized controlled trial in rural Malawi, known as Addressing Hidden Hunger with Agronomy. Data collection included ten focus group discussions, fourteen key informant interviews, two workshops, observations of five trial-related meetings, and review of fifteen reports spanning the trial from planning to implementation. RTREA helped uncover social and ethical issues and provided insight into participants’ lived experiences within the trial. The BT worked alongside researchers to create dedicated “conversation spaces” for discussing these concerns, emphasizing participatory approaches and collaborative problem-solving, which enabled participants’ voices and experiences to be directly incorporated into trial activities. Embedding RTREA demonstrated the benefits of ongoing, real-time engagement between participants and researchers. Such approaches can complement traditional ethics oversight, reinforcing principles of inclusion, autonomy, and empowerment, while promoting ethical awareness among researchers. This heightened ethical mindfulness may also contribute to improved operational outcomes, including higher recruitment, retention, and adherence rates.
