Basics of Qualitative Health Research

Doaa Oraby: Basics of Qualitative Research Basics of Qualitative Health Research Doaa Oraby 1 Doaa Oraby: Basics of Qualitative Research Introduction to Qualitative Research Research is seeking evidence to answer a question. Research involves a systematic approach to finding things out. The process begins with deciding on a research question. It is then necessary to conduct a literature review and to decide on a research design which addresses the research question. Decisions made at this point include considering what kind of data will be collected, how they will be collected, who will be invited to participate and how the data will be analyzed. There are many different methods that we can use to collect evidence for research, depending on what information we are looking for, and on what is appropriate given the situation. Using multiple methods can help ensure we get more comprehensive information. All research, whether quantitative or qualitative, must involve an explicit, disciplined, systematic approach to finding things out, using the method most appropriate to the question being asked. Qualitative research aims to understand the experiences, perceptions and attitudes of patients, the community or health care worker and to answer questions about the ‘what’, ‘how’ or ‘why’ of a phenomenon rather than ‘how many’ or ‘how much’, which are answered by quantitative methods. Qualitative research aims to help us to understand the social world in which we live and why things are the way they are. In a health care setting, qualitative research seeks to answer questions about: • Reasons why people behave the way they do in health and illness. • Exploration of concepts or views related to health and illness. • Assessment (before) and Evaluation (after) implementation of an intervention. • Sensitive topics where flexibility is needed to avoid causing distress. • People’s experiences of health needs, health care, accessing care and keeping healthy. • Understanding different perspectives, such as those of professionals and patients. • How experiences, attitudes and life circumstances affect health needs and behaviors. 2 Doaa Oraby: Basics of Qualitative Research Research questions involve identifying what is happening or being experienced, rather than measuring how much of something exists, or focusing on the way changing one thing produces a change in another for example; (a) reasons why some women might not get family planning services when they need it; or (b) professionals’ views of using family planning methods before the first child. For the research to proceed, it is crucial to become more precise. A qualitative research question does not make prediction. As a qualitative study progresses, the research question should be refined and may be reformulated. Before proceeding you may like to check that: is the area little researched, is it identifying new issues in a “real-life” context, do the researchers need to find out people’s views or experiences of something or observe a process in depth. 3 Doaa Oraby: Basics of Qualitative Research Differences between Quantitative and Qualitative Research Quantitative research provides a broad picture when used to collect data on health, risk, illness, and health-seeking behavior. They help to answer descriptive questions such as: What is going on? What is the scope of the problem? How is the problem changing over time? They are also used to assess similarities, differences, and associations (for example, of a risk factor with a given illness) in the data through statistical analysis. It is important to recognize that the quantitative researcher has to make fixed decisions about what s/he is going to measure and compare. Qualitative research on the other hand, does not take categories of health, risk, and illness for granted. Instead, the qualitative researcher tries to ascertain how people who experience these conditions themselves define what they are going through, when they decide to seek treatment, what happens when they seek treatment, how their experience of illness impinges on their lives and so on. Quantitative data is information expressed in terms of measurable numeric values. Examples are data from surveys. Quantitative data is useful if you want to know how general or common something is, or when you want to know about the frequency of a certain phenomenon. i.e. how many. To collect quantitative data, you have to ask closed-ended questions, so the answers can be categorized and counted. Questionnaires and services statistics are examples of quantitative research. Pros: it does not depend on researcher’s skills - gives a good overview of things that count for a big group of people. Cons: not in-depth, no opportunity to ask for explanations and if topic is sensitive then there is a high chance that respondents report down something different than their actual behavior or opinions. Qualitative data is information in the form of descriptions that cannot be written in numbers. Examples are stories about feelings, meanings, experiences, attitudes and beliefs. Qualitative data is gathered with the aim to understand something, like behavior and the reasons why and how something happens. To collect qualitative data, you have to ask open-ended questions that start with why and how. Interviews and focus group discussions are examples of qualitative research. 4 Doaa Oraby: Basics of Qualitative Research Data can also be collected through observations, if that helps the researcher to understand something better. Pros: detailed information that help you to understand something - If it is carried out well, the information is more trustworthy compared to quantitative data and therefore these methods are better to use for sensitive themes like sexuality. Cons: more difficult to carry out well, because it needs good researcher skills. The kind of data collected depends on what questions researcher asks and how s/he asks the questions, on the setting and whether s/he has rapport with the informant. Data is collected with less informants and therefore less representative for a bigger group. Mixed Methods Research: Qualitative research can complement quantitative data. For example, a qualitative phase of research might precede quantitative data collection in order to explore a new area, to generate hypotheses, or to help develop data collection instruments. In turn, qualitative research might follow a quantitative phase of research in order to elucidate and explain the ‘numbers’ or to probe the issues more in depth with a smaller number of individuals. The survey identifies the extent of the problem, and the interviews can be used to give some of the detail, and the story of how an intervention have affected people. In situations where little is known, it is often better to start with qualitative methods. It can help you with generating hypotheses that can then be tested by quantitative methods. For instance, in an area where we had no idea what kinds of issue were acting as barriers to health care, it would be difficult to design a survey to cover the main factors. Once these have been identified, then a quantitative approach (such as a survey) can be used if you need to measure to what extent these issues are typical for the whole population. 5 Doaa Oraby: Basics of Qualitative Research Sampling for Qualitative Research In quantitative research we are used to generating a sample that is representative of the wider population, which allows us to generalize about that population. In qualitative research the way the sample is designed, and sample size chosen, depends on the aims of the researchers who are not interested in being able to generalize at a statistical level but rather to capture variations in informants’ perspectives and experiences related to the research question. While the aim is not to be able to generalize statistically, it is useful to think in terms of minimizing sample bias. This simply means that although people you are selecting will not represent all people in the population but we can aim to include a range so that the research does not have obvious limitations, such as only including older women, if we are interested in all women, or choosing just people who are in touch with the clinic. Common Types of Sampling Methods in Qualitative Research: Purposeful sampling: To illustrate characteristics of particular groups of interest to facilitate comparisons. Example: Interviewing women who delivered normally and those who delivered via caesarian section for breast feeding experiences. Snowball or chain sampling (locate one or two key individuals, and then ask them to name other likely informants): To facilitate the identification of hard-to-find cases. Example: Finding people living with HIV to interview about health challenges by getting cases referred through friendship networks Maximum variation sampling (purposely select a wide range of variation on dimensions of interest): To document diverse variations; can help to identify common patterns that cut across variations. Example: Researching variations in norms about the acceptability of wife beating by conducting focus groups: young urban women, old urban women, young rural men, old rural men, women who have been abused, women who have not experienced abuse 6 Doaa Oraby: Basics of Qualitative Research Convenience sampling: (select whoever is easiest, closest, etc.): To save time, money and effort. Information collected has very low credibility. Example: Forming focus groups based on who is available that day at the local community center rather than according to clear criteria Criterion sampling: To investigate in depth a particular type of case; identify all sources of variation. Example: Specifically interviewing only women who had their IUD removed during the first three month of insertion to better understand the variety of factors that led to that decision. Sample Size Sample sizes are typically small in qualitative work. One way of identifying how many people you need is to keep interviewing until, in analysis, nothing new comes from the data – a point called saturation even after you have tried to ensure that your new cases are those most likely to extend or challenge your ideas. For interview studies, as a rough guide, theoretical saturation will probably be reached after 20-60 interviews or around 15 people for any homogeneous group (which could be based on age, gender, skill). A study using focus groups to collect data should include several groups, not just one, because any individual group is subject to internal or external factors of which the investigator may be unaware. On a practical level, there may be individual groups that do not go smoothly: the members may be reluctant to participate or not interact well with each other and limited insight will be gained. Enough groups should be run to provide adequate breadth and depth of information; there is a tendency for 10 to 15 groups per study but some studies may find that 4 or 5 are enough. There is no upper limit on the number of focus groups that could be held although this will be limited by resources. 7 Doaa Oraby: Basics of Qualitative Research Qualitative Research Approaches The most commonly used approaches in health-related research include: Ethnography: is a methodology for descriptive studies of cultures and peoples. The cultural parameter is that the people under investigation have something in common. Examples of parameters include: • geographical - a particular region or country • religious • social / familial • shared experience In health care settings, researchers may choose an ethnographic approach because they suspect that learning about the prevailing culture will help us to understand the state of patient care. For example, the way that staff habitually carry out their roles in a clinic, may contribute to factors which affect patient utilization of the services. Ethnographic studies entail extensive fieldwork by the researcher. Data collection techniques include both interviewing and observation. Ethnography can include undertaking a case study. One of the most common uses of the case study is the evaluation of a particular care approach. The purpose of case study research is to describe that particular case in detail and the case under study is not necessarily representative of similar cases and therefore the results of the research are not generalizable. The usefulness of a health service would be determined by a number of local factors and an evaluation of the service would take those factors into account. If the service works well, it does not automatically mean that the service would work equally well in another part of the country. Grounded Theory: It attempts to understand how participants make sense of their experiences. The explanations that emerge are used to develop new theories. In health care settings, the new theories can then be applied enabling us to approach existing problems in a new way; for example, health promotion or the provision of care. Various data collection techniques are used to develop grounded theory, particularly interviews and observation. 8 Doaa Oraby: Basics of Qualitative Research Qualitative Research Data Collection Methods The most commonly used methods include: 1) Interviews 2) Focus group discussions 1) Interviews Interviews resemble everyday conversations but they are focused on the researcher’s needs for data and we are concerned to conduct them in the most rigorous way we can in order to ensure trustworthiness. Both the researchers and the users of the findings need to be as confident as possible that the findings reflect what the research set out to answer, rather than reflecting the bias of the researcher, or a very atypical group. Most commonly interviews are audio recorded after obtaining consent. Interviewing can be structured, with questions prepared and presented to each interviewee in an identical way using a strict predetermined order or completely unstructured like a free-flowing conversation. Qualitative researchers usually employ “semi structured” interviews which involve a number of open-ended questions based on the topic areas that the researcher wants to cover. A research interview is not like a clinical interview or an interrogation. The aim is to be as nonjudgmental as possible, and not to lead the respondent to particular answers as you are interested in their views, not their responses to your views. Interview Guide: Preparation for interviews includes developing a topic guide which is a list of topics the interviewer wishes to discuss. It is very important to develop the right question to ask and to remember that the respondent is unlikely to share your perspective on the world. A topic guide usually has a list of the key questions the interviewer would like to cover, with some useful probing questions to encourage the interviewee to talk about specific issues if they do not come up spontaneously. The interview needs to be conducted sensitively and flexibly allowing follow 9 Doaa Oraby: Basics of Qualitative Research up of points of interest to either interviewer or interviewee. In addition to the topic guide, the interviewer should also prepare the introduction part, the consent form and the voice recorder. It may take a while to develop the right question for getting precisely the kind of data you are interested in. Pilot questions with colleagues first – does it make sense? Do they respond in the ways you expected? Then pilot them with people similar to your participants. Sometimes small changes in how you ask can make a large difference to the information you are given. Closed-ended question versus Open-ended question: The open-ended questions provide opportunities for both interviewer and interviewee to discuss some topics in more detail. Do you think the information brochure is good? What do you think about the information brochure? Is the service provider friendly? Can you tell me about your visit to the clinic/service? Did you find the meeting useful? How did you like the meeting? What did you think of the meeting? Did you learn from the peer educator? What have you learned? What information have you used from the peer educator? Was the research training good? How was the research training? What did you think of the training? Probing questions: In a semi structured interview, the interviewer also has the freedom to probe the interviewee to elaborate on an original response or to follow a line of inquiry introduced by the interviewee. Probing questions help you to get in-depth information. Often you can ask more than one probing question after one entry point, or you can ask the same probing question but in different ways. For example: “Why/how?” , “ Can you explain?” , “ How does that work?” , “ Can you give an example?” “ How does that make you feel?” , “ What is your experience with this?” , “ What do you think of this?” Sometimes you can repeat an informant’s sentence in a questioning 10 Doaa Oraby: Basics of Qualitative Research manner instead of asking a ‘why’ question. For example: “ You said you think she does not want to use contraceptive pills?” Interviewing Tips A good interviewer needs to be able to put an interviewee at ease, needs good listening skills and needs to be able to manage an interview situation so as to collect data which truly reflect the opinions and feelings of the interviewee concerning the chosen topic. The interviewer needs to think about a number of issues before starting and while doing the interview as follows. Access: How are you going to gain access to the people you need to interview? it might be possible to get a doctor to ask patients whether they want to be interviewed; you could also use key informants (community leaders, teachers). However, if using health care workers or other informants to ask for participants you need to consider: Ethical issues: make sure the informant is not persuading or coercing people to take part. Bias: Health care workers will only have access to patients, not to those not accessing services. Teachers or community leaders might favor the high-status respondents, or those they think will give you the answers you want. Setting: The place where you will do the interview will have an impact on the answers that you will get. A quiet, comfortable location should be chosen, make sure there is enough privacy for the interviewee to feel comfortable in giving honest answers, and organize the space to make sure the interviewee is relaxed. Rapport: The word rapport refers to the degree to which a researcher and an informant relate to each other, experienced by the informant as feeling that the researcher understands him or her, that he or she can trust the researcher and that it feels like talking to a friend. All qualitative researchers need to consider how they are perceived by interviewees and the effects of personal characteristics such as status and gender for example it might be sensible not to conduct interviews with your own patients if you are their doctor. The interviewer should give consideration to how he/she presents him/herself in terms of dress and manner so as to be approachable. Wearing a lot of 11 Doaa Oraby: Basics of Qualitative Research expensive jewelry and clothes could be intimidating, but a scruffy appearance might make interviewees feel disrespected. The interviewee needs to trust you. This means that you have to show that you are interested in them and what they have to say, and most importantly that you will not judge them whatever their answers. You will therefore need to start by introducing yourself, the aims of the interview, a reminder that the interview can stop at any time (should the interviewee feel uncomfortable/unhappy), and allow time for questions before you start the interview. You will need to be sensitive to the needs of your respondents. They will need to be comfortable and helped if they are weak or do not hear well, for example. There are several verbal and non-verbal communication skills that can increase the rapport that you can build with your informants including; don’t judge and stay neutral, treat the informant as the expert, show respect, listen with genuine interest and attention and don’t interrupt, ask questions clearly and use language and words that the informant can understand, use the correct tone of voice, ask gently, be friendly and allow for a few seconds of silence, so the informant can add anything if he/she wants. Conducting the Interview In the introduction you will have to: • Explain who you are and which organization you are with (show a card or badge if applicable) • Explain the purpose of the research: what the research is about and why it is being conducted • Explain why you need this person to help you and how you are going to use the information given by him/her • Explain to the informant his/her rights: >> That you guarantee anonymity and confidentiality >> That the informant can withdraw his/her participation in the research at any point during the interview without having to give an explanation 12 Doaa Oraby: Basics of Qualitative Research • Ask if the informant has any questions before you start • Ask if he/she wants to participate in the research (informed consent). If you are using signed informed consent papers, ask the informant to read the consent form and sign it. • Obtain consent for recording the interview (digital voice recorders are excellent for this and easier to use and less intrusive than tape recorders). During the Interview • Start with a general question to orientate interview to the topic • Use everyday vocabulary, don’t use technical words or overly complicated ones • Put more sensitive questions towards the end • Ask open questions, i.e. requiring more than ‘yes’ or ’no’ in answer • Ask neutral questions. For example, do not ask: ‘why haven’t you had your children immunized’ but rather ‘how did you decide whether or not to immunize your children’? • Use concrete rather than abstract questions. For example, ‘think about last time you were pregnant. What did you like about services then?’, rather than ‘what do you think about ante-natal services?’ • Use concrete events to help people remember – eg ‘After your last child was born’ • Check whether you have understood respondents’ meanings instead of relying on your own assumption. Things to avoid while interviewing: • Competing distractions (such as children) • Asking interviewee embarrassing/ awkward questions • Asking leading questions. These are questions that may suggest a specific answer. e.g. instead of asking: ‘Did you take the drugs exactly as the doctor advised?’ ask ‘Tell me how you used the drugs...’ • Jumping too quickly from one subject to another. • Having more than one idea per question to ensure focus. • Teaching, for example giving interviewee medical advice. • Presenting your own perspective, thus potentially biasing interview. • Remaining at a superficial level by asking questions too rapidly. 13 Doaa Oraby: Basics of Qualitative Research • Interruption from outside (people intruding, etc) should be minimized as much as possible. Concluding the Interview: At the end of the interviews, thank the informants for their time. Ask if they have questions or if there is anything, they are not clear about. Reassure them about confidentiality. Give them the compensation for their time and reimburse their travel expenses if they have any. Offer them drinks or snacks if this is appropriate. It is very important in any interview that you do not create expectations which you cannot fulfil. Don’t lead people to believe that you will accomplish more than you are able. Reflecting on the Experience: Listen to your recorded interview and answer the following questions in your notes. • How did the interview go? • What went well? What didn’t go well? • What did I do well? What would I do differently if I were to do this interview again? • Where did I get stuck? • Did I listen well? Did I interrupt the participant? Did I ask questions that elicited more detail? • Did I pick up on cues from the participant? Which cues did I miss? 14 Doaa Oraby: Basics of Qualitative Research 2) Focus Groups Group interviews are conducted when qualitative researchers want to explore commonly held views on a topic. It is assumed that a group of people with common characteristics or experiences can provide an understanding of the shared knowledge on a particular topic, as opposed to the unique views and experiences of an individual. In a way focus groups resemble interviews, but focus group explore the ways in which the participants interact with each other and influence each other’s expressed ideas, which obviously cannot happen with one-to-one interview. Focus groups use topic guides to help them keep the discussion relevant to the research question and work best when conducted by two researchers; one researcher facilitates the discussion and the other researcher takes detailed notes during the discussion. Advantages • Focus group discussions yield a large amount of information over a relatively short period of time. • Focus group discussions are effective for accessing a broad range of views on a specific topic, and for capturing information about social norms. • Focus group discussions are well suited for research that will be used to develop or measure services that meet the needs of a given population. Disadvantages • Focus group discussions are not the best method for acquiring information on highly personal or socially sensitive topics. • Confidentiality of participants is difficult to ensure as numerous members of the community are present and participating in the discussion. • Focus group discussions are difficult to facilitate because they involve ensuring that everyone gets a chance to speak and contribute. The Focus Group Discussion Guide Preparation for focus group includes developing a topic guide which is a list of topics the facilitator wishes to discuss. The guide usually has a list of the key questions the facilitator would like to 15 Doaa Oraby: Basics of Qualitative Research cover, with some useful probing questions to encourage the participants to talk about specific issues if they do not come up spontaneously. Generally, the order of questions should be as follows: • Early questions should be directly related to topic of research. • Most relevant/interesting questions should be asked as soon as possible to interest the participants. • Sensitive questions should be left till later. • General questions before specific ones. Organizing a Focus Group If you want to organize a focus group, you will need to think about the following issues: • How will you recruit the participants? • Where will you hold the sessions? • How will you run the groups? • How will you record the data? Recruitment of focus group participants To recruit your participants, you can ask for volunteers from the population of interest, or ask for the help of gate-keepers, leaders or contacts in the community who can invite participants for you. The other option is to recruit people systematically from a sampling frame for the population of interest, if available, for example use the list of all patients from a particular clinic, and invite every tenth person. The members of each focus group should usually have something in common: characteristics which are important to the topic of investigation. For example, they may all be members of the same profession or they may all be patients who have experienced a similar health problem or receiving similar treatment. Participants might or might not know each other. Focus groups are considered to work well with approximately 8 people, groups typically have between 6 and 10 people. Below 6, it may be difficult to sustain a discussion; above 10, it may be difficult to control it. If you aim for 10, it is usually a good idea to over recruit; invite more in the expectation that one or two will not turn up. 16 Doaa Oraby: Basics of Qualitative Research Location of focus group Focus groups are ideally conducted in accessible locations where participants can feel comfortable and relaxed. The time of day will need to be appropriate for the particular target group. Make sure that you have your discussion in a quiet, comfortable place so that people feel relaxed and inclined to speak. Organize the seating in a circle, so people can see each other. Try to arrange child care arrangements if your target group includes mothers so that they can attend and actively participate. Running a focus group discussion Focus group discussions are conducted by two researchers: facilitator and note taker. The facilitator is responsible for leading the discussion, asking all the questions specified in the focus group question guide, keeping the discussion on track, and encouraging all participants to contribute. The note-taker is primarily responsible for taking detailed notes of the discussion, facilitating logistics of the focus group, and recording of the session (operating the recorder, labeling the recorded session, and taking appropriate measures to protect the records once the session is over), and handling any external distractions that come up during the focus group discussion. It is better to offer refreshments and to point out toilet facilities beforehand to avoid interruptions during the discussion. Serving refreshments as people arrive also serves as a good ice-breaker and allows participants to meet each other before the focus group starts. The facilitator should begin by greeting the participants and clarifying his/her role, as well as the role of the note-taker then informing them about the purpose of the research, the topic of the discussion, and how the data will be used and who will have access to it. Then the facilitator should ask the participants for their consent to participate and to record the session while affirming their right to withdraw at any time and clarifying that refusal to participate or withdrawal at any time will not have any negative influence on them. The facilitator should then lay down the ground rules and one of these is confidentiality which needs careful planning at the proposal and ethics committee application stage. Participants of the focus group will not speak openly unless they are comfortable that others present will treat their contributions as confidential. All participants should indicate their agreement that it is expected that the content of the discussion which is about to take place will only be known by those present. 17 Doaa Oraby: Basics of Qualitative Research Other ground rules include respecting each other’s opinion, no interrupting any one and silent mobile phones. Another point to make clear at the beginning of the focus group is the planned completion time for the discussion. Focus groups should last about 90 minutes but it is better to announce to the group that it will take two hours. Discussion The facilitator begins the discussion with the discussion starter question from the focus group question guide. A key feature of the discussion-starter question is that everyone should be able to respond to it easily to get everyone on record with their different experiences and opinions for example getting each participant to say one thing about their experiences of the last time they used the local clinic. After this first discussion starter, the facilitator can start tapping into the topic guide while relating the questions to what has been mentioned during the opening statements. Throughout the discussion, the facilitator ensures to address all questions or topics listed in the focus group question guide. The facilitator uses listening skills, facilitation skills, and probing questions to elicit discussion from participants, sometimes challenging participants, drawing out differences in opinion, asking for details and tactfully moving things forward when the conversation is drifting. The facilitator will also need to ensure that everyone speaks while not favoring any particular participant. The facilitator must allow all participants to express themselves and must cope with the added problem of trying to prevent more than one person speaking at a time, in order to permit identification of the speakers for the purposes of transcription and analysis. The note taker notes which participant is saying what, which can be done if each person is labelled with a number or letter and the relevant label is noted alongside the first word or two of his/her contribution in addition to noting on body language, attitudes and checking the recorder. Closing the focus group discussion To indicate that the discussion is coming to a close, the facilitator could ask each participant for a final summary statement within which he/she should ask them to point out what they think are the most important points which will help the analysis part. Then thank the participants for their time and energy. Ask them if they have questions, or if there is anything, they are not clear about. Reassure them about confidentiality. Give them the 18 Doaa Oraby: Basics of Qualitative Research compensation for their time and reimburse their travel expenses if they have any. Offer them drinks or snacks if this is appropriate. After participants leave, the two researchers should debrief and share additional insights on the discussion. 19 Doaa Oraby: Basics of Qualitative Research Managing and Analyzing Qualitative Data Transcribing Qualitative Data Transcribing is the procedure for producing a written version of an interview or focus group discussion. After completing the interview or the focus group discussion, the recording needs to be transcribed. This involves writing down, word-for-word, what was said including pauses, laughter, and other such occurrences. The transcription should be supplemented with the notes taken during the interview or the focus group. The transcripts should be kept safe and secure without identifying information. Transcribing is a time-consuming process. The estimated ratio of time required for transcribing interviews/focus groups is about 6:1. This means that it can take six hours to transcribe a one-hour. The research team should at an early stage consider the question “who should do the transcribing?” Ideally there might be resources to pay a professional transcriber who is aware of the need for confidentiality. This is usually more cost effective than a health care professional who will take longer and is more highly paid. If the transcriber is unfamiliar with the terminology or language contained in the interviews/focus groups this can lead to mistakes or prolong the transcribing time. All transcripts should be carefully checked by the researcher in conjunction with the recording. On the other hand, some researchers find that the process of transcribing helps them to become immersed in the data and is therefore a useful step in the process of interpreting the data and helps in answering the research question. Analysis of Qualitative Data Analysis of qualitative data is often seen as the most difficult part of the research; yet it is very enjoyable to see patterns emerge and be able to draw out some meaningful conclusions of all the interviews and group discussions. It is crucial to be able to provide a record of what has been done and why at all stages. The most common method for analysis of qualitative data is thematic analysis. A thematic analysis is one that looks across all the data to identify the common issues that recur and identify the main themes that summarize all the views you have collected. The key stages in a thematic analysis are: 20 Doaa Oraby: Basics of Qualitative Research 1. Getting to know the data Once the transcription is done, read all the transcripts and field notes from the beginning to the end. Reading and re-reading helps you to familiarize yourself with your data and the context within which they were collected, particularly if data collection has taken place over a long period of time and you have forgotten some of the detail from your early material. It is useful to have a short summary of the main issues arising in each interview or focus group transcript that you can refer to later. 2. Identifying themes Go back to the original research question and consider the themes that you expected and write a list of these expected research themes. You can use this as a starting point for thinking about the themes coming out of your data but make sure to remain open to new and unexpected ideas that emerge from your data. Start making a list of; recurrent themes, new themes and differences within the themes as expressed by the informants. Themes might be divided into sub-themes depending on the data you have and the variation in the data across informants. For example, this extract comes from an interview with a woman about seeking health care: 1. I was six months pregnant and had bleeding in the morning 2. I was afraid losing my baby 3. my mother-in-law said to lay down in bed 4. but bleeding continued and I knew it was not right 5. and I told my husband to hurry to get me to the clinic We could just see this as an example of the theme (management of bleeding), but we will get more out of the data if we think in detail about the various different things that are going on here, such as: sources of information and advice; remedies; triggers to health care seeking. 3. Setting up a coding system Once you are satisfied with the list of themes and subthemes, you will need to translate this list into a set of codes. Whether you intend to code manually or to use a software package, you must 21 Doaa Oraby: Basics of Qualitative Research come up with a way to define codes that will be used to signify your themes and sub-themes. These can take a variety of forms: Abbreviations- e.g., HBC – Home Based Care; UN – United Nations; HOSP –Hospital, etc. Words - e.g., Health, fear, professional activity, etc. Numbers - e.g., 1001, 2023, 4045 Using colors to highlight a theme (e.g., green: relationships; blue: health and access to health services). It is useful to begin developing the coding scheme as soon as initial data have been collected. This early analysis can help shape later data collection (are we asking the right questions? Have we included the right people?) as well as giving feedback to the interviewers. Whenever possible, develop the coding scheme with colleagues to avoid going down narrow analysis paths and ensure that individual bias about what is going on is kept in check. 4. Coding Now that you have set up a list of codes, you can start coding the text. This means that you will apply one or several codes to a portion of the text. Read each sentence, one paragraph at a time and think carefully about the text and its meaning; does it correspond to one of the codes? If it does, then highlight it and note the code in the margin or if using computer software, mark the text on line. Coding is a laborious exercise and time is needed to do it properly. Beware of assigning too many codes to short sections of text as this will lead to data lack of context or using a code for a large chunk of text as data may refer to many more themes than indicated by the code you have used. 5. Cut and Paste When all the data have been coded, you can cut data extracts out of the interview or focus group transcripts and paste them together with other examples of data on the same topic codes. It is vital to know where the extracts you are cutting and pasting came from to be used as quotations supporting themes and subthemes in the study report. 22 Doaa Oraby: Basics of Qualitative Research Cutting and pasting can be done manually or with computer packages designed for this kind of analysis. For small data sets, it is not usually worth investing in computer aided analysis packages. However, for a large data set, or data spread across many sites, and with different people working on it, it is worth the effort as they facilitate easier management and retrieval of data. Some examples of popular software packages are: NVivo and Atlas-ti. Using a software will help organize your codes, but no software will do the coding for you as coding is not straightforward and you will need to think critically about the meaning of each portion of the text in order to apply a code to it. 6. Displaying Data Displaying data means capturing the variation of each theme and noting differences between individuals or among subgroups. Start by developing detailed notes related to each main code in your coding scheme. Then identify the principal subthemes that emerge from the data within a single coding. Once the principal subthemes of the code have been identified, return to the data and examine the evidence that supports each subtheme with special attention to the specific vocabulary that participants use to discuss the topic. Consider differences in the intensity or emphasis with which participants express an idea. For example, in a study of family planning use, women interviewed expressed opinions on the possibility of using contraceptive pills in secret by women whose husbands are against family planning. Most participants have taken a clear stand on this issue and their responses could initially be classified as supporting or rejecting the secret use. As analysis continues, subthemes that reflect finer distinctions were displayed. Subthemes for reasons for rejection were identified including; the subtheme of partner bonding “ It is better for us to know as a family” and the subtheme of fear of consequences “ He will catch you using [it], and he will divorce you” with more emphasis directed to the subtheme of partner bonding. 23 Doaa Oraby: Basics of Qualitative Research Example of Thematic Analysis The following themes were identified from analysis of data yielded from a study exploring reasons beyond the low uptake of youth friendly services: Need: Are the services offered to young people relevant for them? do they match what they need, their primary concerns and realities? Demand: Are young people motivated to use the services that are offered? Awareness: Do young people know about the existence of services and their location? Access: Are services able to attract and reach young people? Are they acceptable and affordable and are they easy and comfortable to use? Quality: Do young people perceive the services as helpful and relevant? Are they happy with how they are treated? Are services respectful of their rights as clients? Support for Service Providers: What do service providers need in order to offer youth-friendly services? Is there sufficient organizational support, management systems and resources and training and motivation of staff in order for them to conduct their jobs in the best possible way? Interpretation At this stage you have pages full of interesting themes, subthemes and supporting quotes. Start looking for patterns and relationships under these themes which will form the basis of your report. Interpretation is the act of identifying and explaining the core meaning of the data and communicating the essential ideas of the study to a wider audience while being faithful to your participants’ perspectives. Although the meaning that you extract from your analysis should reflect the intent of your study participants’ responses, it must also provide answers to questions of social and theoretical significance. For example, in the extract that came from an interview with a woman about seeking health care, the role of mothers in law in the decision of seeking health care can be focused on in a section of the study report. 24 Doaa Oraby: Basics of Qualitative Research Validity and Reliability of the Findings It is important to ensure that your analysis is reliable and valid. Triangulation is a way of assuring the validity of research through the use of different methods of data collection. For example, if you have done interviews and focus groups, compare the findings from each. If they coincide, that strengthens our faith in having identified important issues. Validity of findings can also be increased via member checking. This involves feeding findings of the analysis back to the participants, through focus groups for example, and assessing how far they consider them to reflect the issues from their perspective. A key element of improving validity is dealing with what are known as deviant findings: these are those that do not fit with your conclusions. Be sure to look in detail at the deviant findings, and account for why they differ. Explaining this will strengthen your analysis. To ensure reliability of your analysis, you will need to maintain meticulous records of all the interviews and group discussions and document the process of analysis you went through in detail. 25 Doaa Oraby: Basics of Qualitative Research Presenting Qualitative Health Research Whatever the audience or the form of the presentation, a good starting point is the research question. If you are clear what question you set out to address, it will be easier to make sense of the mountains of data you have generated and to present an interesting, meaningful report or presentation. Your analysis will probably have generated a number of themes and a good way to structure the results section of a research report is to use, as subheadings, the main themes which emerged from the data. Further evidence to support the findings is usually provided by using direct quotations from respondents. Key quotations should be selected to illustrate the meaning of the data. There are three basic factors that influence how much emphasis to give a topic in your presentation or final report: 1) how many individuals/ groups mentioned the topic, 2) how many people within each of these groups mentioned the topic, and 3) how much energy and enthusiasm the topic generated from the participants. Oral Presentation of Qualitative Findings Oral presentation of qualitative findings is very similar to presentation of quantitative study results, with the difference that quotations from participants replace statistical summaries of the data. As with all dissemination formats, be sensitive to audience needs and expectations; know what contextual information will be important to provide; and focus on the main research question, paying attention to the quality of what you say. When structuring your oral presentation, include the following sections: Opening: Set the scene by telling a story that will interest your audience. Introduction: Tell your listeners what your presentation will cover • What health issue did you study? • Why did you conduct the study and why was it important? • What questions did you ask? and how did they evolve as you analyzed initial responses? 26 Doaa Oraby: Basics of Qualitative Research • What methods did you use, and how close did you get to the participants in the study setting? • Which results will you discuss? Body of the talk: Discuss your results sequentially, and relate them to your research questions. Clarify each point by using examples and presenting selected quotations from study participants to illustrate major findings. Offer your interpretation of how applicable the findings may be to other settings, and describe the limitations of your work. Summary: Summarize for the audience the important points in your talk and identify areas that need further study. Tips for a successful qualitative study presentation: • Remember that you are sharing the words and experiences of people who entrusted their stories to you. • Do not be afraid to try presentation formats that convey the drama and emotion of their lives. • To hold your audience’s interest and to share ownership of the findings, consider inviting a stakeholder to co-present the findings. • Keep slides short and simple. • Practice giving your talk beforehand. Qualitative Health Research Report In writing up findings of qualitative research, you have to remain focused on the research questions and objectives while linking the questions to the findings. In qualitative research the study findings are the researcher’s insights from categorization of the data, identifying key themes, describing how they fit together, and understanding how they fit in the larger sociocultural context. Quotations from participants, should not be considered or presented as results but rather as illustrations of insights arrived at through your analysis. The report should include the following: 27 Doaa Oraby: Basics of Qualitative Research I. Introduction A. Literature review 1. Relevant facts from previous studies 2. Questions unanswered by previous studies B. Purpose of the study 1. Main question and summary of basic approach used to answer it 2. Anticipated contribution of study results C. Brief description of the study 1. Who did the study, where, and when 2. Brief description of the methods and participants 3. Description of relevant cultural or contextual information II. Methods A. Study design B. Sampling methods C. Data collection methods D. Data analysis methods III. Results A. Presentation of the results B. Interpretation of the findings C. How the results relate to earlier studies D. How methodological difficulties could have affected results IV. Conclusion A. Importance of the results to others thinking about the problem 28 Doaa Oraby: Basics of Qualitative Research B. Implications of findings for the specific purpose of the study V. Recommendations A. Policy or service delivery recommendations B. Community action recommendations (if applicable) VI. References 29 Doaa Oraby: Basics of Qualitative Research Bibliography • Denzin NK, Lincoln YS (eds.)2000. Handbook of Qualitative Research. London: Sage Publications. • Family Health International 2005. Qualitative Research Methods: A Data Collector’s Field Guide • Hancock B., Windridge K., and Ockleford E. 2007. An Introduction to Qualitative Research. The NIHR RDS EM / YH. • Kielmann, K., Cataldo, F. and Seeley, J. (2012). Introduction to Qualitative Research Methodology: A Training Manual, produced with the support of the Department for International Development (DfID), UK, under the Evidence for Action Research Programme Consortium on HIV Treatment and Care (2006-2011). • Michael Quinn Patton and Michael Cochran 2002. A Guide to using Qualitative Research Methodology. • Pope C, Mays N. Qualitative Research in Health Care. London: BMJ Books, 2000. • Priscilla R. Ulin, Elizabeth T. Robinson and Elizabeth E. Tolley. 2005. Qualitative Methods in Public Health: A Field Guide for Applied Research. • Rapport, F., Hogden, A., Faris, M., Bierbaum, M., Clay-Williams R., Long, J., Shih, P., Seah, R., and Braithwaite, J. (2018) Qualitative Research in Healthcare – Modern Methods, Clear Translation: A White Paper. Australian Institute of Health Innovation, Macquarie University: Sydney, Australia. • Shallwani S. and Mohammed S., 2007. Community-Based Participatory Research: A Training Manual for Community-Based Researchers. 30