Qualitative Research Methods Training Course

1. Qualitative Research Methods Training Course Kampot Province, Cambodia 10-16 November 2003

2. Research Question: Who are the health providers in the village and what care do they provide?

3. Training objectives • 1. To familiarize the participants with the principles and practice of qualitative research methods in public health • 2. To discuss a mix of qualitative methods and their application in public health research and programming • 3. To practice using qualitative research methods in an applied context

4. Qualitative Research Methods • Social mapping • In-depth interviews • Observation • Free-lists and ratings

5. Meaning of Methods • Epistemology or the study of how we do things • At a general level, it is about strategic choices, for example, whether we do participant observation fieldwork, document analysis or an experiment 3. At the specific level, it is about what sample you select, whether you do face to face interviews or use a telephone or use an interpreter or learn the language and do the interviews yourself

6. Rationalism is the idea that human beings achieve knowledge because of their power of reason. That is, there are a priori of truths, and if we prepare our minds adequately those truths will be evident to us.Versus Empiricism, who consider that the only knowledge that human beings acquire is from sensory experience. They consider that we are born with brains like empty boxes and that boxes are filled with the experiences throughout our life. We come to understand what is true from what we are exposed to.

7. Scientific method Science is “an objective, logical, and systematic method of analysis of phenomena, devised to permit the accumulation of reliable knowledge” (Lastrucci, 1963:6).

8. Objective –“the idea of truly objective inquiry has long been understood to be a delusion. Scientists do hold, however, that striving for objectivity is useful. In practice this means constantly trying to improve measurement (to make it more precise and accurate) and submitting our findings to peer review” (Bernard 1995).

9. Method – Each scientific discipline has developed a set of techniques for gathering and handling data, but there is, in general, a single scientific method. The METHOD is based on 3 assumptions:(a) reality is “out there” to be discovered; (b) direct observation is the way to observe it; (c) material explanations for observable phenomenon are always sufficient, and that metaphysical explanations are never needed.

10. Reliable – something that is true in Phnom Penh, for example, is equally true in Kampot Province

11. Social Science Asks questions and seeks to explore the answers • Social science uses various methods to answer the question/s • Most anthropological work is qualitative. In applied anthropology there is a growing interest in mixing qualitative and quantitative research to answer the research question/s • Important not to mix quantification and science. Keep them separate. • Quantification is important in anthropology, as it is in any science. But all sciences are not quantified and all quantification is not science ·

12. Some social scientists do not use quantitative methods, for example, sociologists. • Ethnography does not mean qualitative. As a noun it means a description of a culture. As a verb it is ‘doing ethnography’, and it means collection of data that describes a culture.

13. The rest of the training program will be about methods that will let you build an ethnographic record. Some of these methods involve fieldwork. Some methods involved in building an ethnographic record include, watching, listening. Some methods result in words and OTHERS result in numbers.

14. Qualitative research Inductive Holistic Subjective/insider centered Process orientated Actor’s world view Relative lack of control Goal to understand actor’s view Discovery orientated Explanatory Quantitative research Deductive Particularistic Objective / Outsider centered Outcome orientated Natural science Attempt to control variables Goal to find facts & causes Verification orientated Confirmatory Characteristics of Qualitative and Quantitative Research

15. Quantitative Research • Use numbers and statistics, examples, experiments, correlation studies using surveys & standardized observational protocols, simulations, supportive materials from case studies (example, test scores). • General sequence of research: • Observe events / present questionnaire / ask questions with fixed answers • Tabulate • Summarize data • Analyze • Draw conclusions

16. Culture is the shared traditions, beliefs and life-ways of a group of people

17. Qualitative Research • Use descriptions and categories (words). Examples: open-ended interviews, naturalistic observation (common in anthropology) document analysis, case-studies, life histories, mapping, pile sorts and ratings, descriptive and self-reflective supplements to experiments and correlation studies.

18. General sequence of qualitative research: • 1.Observe events / ask questions with open ended answers2.Record/log what is said (or not said) and done (or not done)3. Interpret (personal reactions, write emergent speculations or hypotheses, monitor methods)4.Return to observe, or ask more questions of people5.[recurring cycles of 2-4 – iteration]6.Formal theorizing [emerges out of speculations and hypotheses]7. Draw conclusions

19. Three key methods 1.Detailed open-ended interviews (not highly structured or limited responses) • Direct observation 3. Written documents (work with words and visual data, not numbers)

20. Strengths of qualitative research • Depth and detail (versus standardized questionnaire) • Openness – can generate new theories and recognize phenomena ignored by most or all previous researchers and literature • Helps people see the world view of those studied- their categories, rather than imposing categories; simulates their experience of the world • Attempts to avoid pre-judgment (this is questionable in reality).Present people on their terms, without being judgmental, try to respect them from their perspective so the reader can see their views (always difficult)

21. Weaknesses of qualitative research • Fewer people studied (usually) • Less easily generalized because of few people / locations in studies • Difficult to aggregate data and make systematic comparisons • Dependent on researchers personal attributes and skills • Participation in the research can always change the social situation (although, not participating can also change the social situation as well)

22. Ten themes of qualitative research • Naturalistic– not manipulating the situation, watch naturally occurring events, not controlling them. • Inductive– categories emerge from observing, creation and exploration centered, theories emerge from data. Often induce hypothesis, test it, then look for other possible explanation or additional hypothesis. • Holistic – look at total, what unifies phenomenon, it is a complex system, see overall perspective. Often research and academics study smaller and smaller parts and overlook the big picture. Need to try and get a larger picture, including the specific and unique context. But can look at specific variables too.

23. Characteristics of Qualitative Research • Personal contact – share the experience, not trying to be the objective outsider. Must know people to understand them, and gain insight by reflecting and being empathetic with them. If try to be objective probably won’t understand their views (but might understand things about them). • Dynamic constant shifting with the changing phenomenon and context: what method fits now and also, use trial and error. Don’t stick with the one method when you know that it is not working. Stop. Realize that things may unfold differently than you expected, go with the flow. Respond creatively. • Unique case selection– not as concerned about generalizability (actually generalization is a cooperative venture of researcher and reader = researcher describes context fully and reader decides if new context is similar in crucial respects)

24. Characteristics of Qualitative Research con’t • Thick description– lots of detail, lots of quotations • Context sensitivity - emphasize many aspects of social, historical and physical context. • Empathetic– trying to take a view of the other person and be non-judgmental. Not subjective in terms of my biases, not objective in terms of no bias, but taking on their perspective to the degree possible. How does reality appear to those being studied. Yet, also reporting own feelings and experiences as part of the data. Try to omit judgments, but freely admit own feelings. Do not try and hide them. Admitting them adds to the validity of the data.

25. Characteristics of Qualitative Research con’t • Flexible design - You don’t always specify it completely before research; variables and hypotheses and sampling and methods are at least partly emergent – need to unfold. Need to be able to tolerate contradictions. Trial and error with categories too – need to reformulate categories many times. Go from parts to whole and then back again. Cycle back and forth. Then reconstruct, pull data apart again, make better reconstructions, etc. Use multiple methods or as many as feasible, as long as you get a better picture of what is happening and how it is understood – even use quantitative methods.

26. Researcher Roles • The ‘traditional’ role for a qualitative researcher is to be nonexistent. This is ideal but not always possible and practical. The ideal is that participant act exactly as they would if you were not present. • Problem – tends to ignore differences made in the environment by the researcher. • Qualitative research states that the researcher should document these differences. • It is difficult to obtain the participants views without interacting

27. Researcher Roles con’t • The presence of the researcher could cause other reactions, eg suspicion, affected behavior, demonstrations for the researcher’s behalf. But time and familiarity tend to blur these responses. In time the researcher becomes part of the environment. But not initially. • Researcher is an instrument in qualitative research. To gather data. People reading the research need to know about the instrument. So, you need to describe relevant aspects of the yourself, your biases and assumptions, expectations, relevant history. Keep track in your field notes personal reactions, insights into the self and past. In a separate journal – write your personal notes.

28. Emic = an insider, become full participant in activity, helps minimize distinction/difference between researcher and participants • Etic = an outside view, A fly on the wall. Lots of variation in between, can vary role within a study – starts as outside and move to membership. Or change to outsider role at end to verify hypothesis generated as participant.

29. Gatekeepers • Initial entry into the field of study • Control access • Problems with / for gatekeepers • Position of gatekeeper in the research • Gatekeepers’ perception of the researchers, eg. Spy • Expectations of gatekeepers on researchers, eg, outcomes such as reports, relationships, money • Compromises • Gatekeepers and problems for the research and researcher • DO NO HARM

30. Access to research subjects • Access to subjects is often challenging for the researcher • Trust and respect is very important • Difficulties when participants are not very verbal • Role of key informant in research process • Positives and Negatives of involving key informant, eg, not always representative view of ‘others’, vested interest in research subject, access to resources, political position, looking for a friend, have problems with others in the community, most educated person, others?

31. Access to research subjects con’t • Stay around the study site early in the research process. This is sometimes called the “mapping phase”, ie, map the area, social context of environment, kinship relations, services or networks. Physical mapping is an excellent way to “meet and greet” and learn about the physical environment. Doing a video often helps. • If physical environment is very familiar, try to look for the ‘other’ aspects of the environment, eg, other health providers

32. Sample and Selection • Study a subsection of a population • Look at selection in a probabilistic manner – try to get a representative sample of the group under study. • Not generalizable for the whole population, but generalizable for the population under study. • Choosing a population to study is dynamic and ongoing. The choice of who to study next are products of what is being found, not the initial plan.

33. Suggestions for accessing subjects 1. Maximum variation of participants, example, women who attend health services and women who do not, different age groups, social and economic backgrounds, and so on. 2. Snowball approach and networking – each person studied is chosen by the previous participant - this will show linkages between participants. This is sometimes the only way to find and obtain a sample of certain population groups, eg, women who have been trafficked for prostitution. 3. Extreme cases – studying one or more people at some extreme. This needs to be included in the sample with the ‘average’ and the ‘opposite’. This may or may not be possible, but you have to seek these people out. There may only be one or two people, but you have to include them.

34. 4. Typical case - decide what characterizes ‘typical’ and go and look for them. 5. Unique case – very rare combination of things – usually found by accident. 6. Ideal case – perfect situation. “if it won’t work here, it won’t work anywhere.

35. It is very important to be able to say how and why you sampled in a given manner. So, keep detailed field notes on the decisions you made about sampling and why you made them. Go into detail in the field notes, give examples and the reasons for the choices you made.

36. Informed consent • Definition of informed consent consists of the elements- information, comprehension, and choice. • Country specific laws provide conditions for informed consent. • Local standards and protocols when conducting research with human subjects • Oral or written consent • Anonymous • Difficulties obtaining informed consent in special populations, for example, children and refugees. • Costs and benefits of obtaining informed consent

37. Ethical behavior in research • Courtesy • Respect • Empathy • Honesty

38. Triangulation TRIANGULATION involves using a combination of methods, researchers, data sources and theories in a research project. Outcomes:Different results will be obtained by using different researchers and different data sources Methods are not neutral tools that will produce the same results regardless of the method. Triangulation addresses this problem.

39. Recording field work data Two types of note-taking • Field-notes • Interview transcriptions

40. Field-notes • Ideal situation is to write field-notes by hand, and at the study site • Field-notes can be written in point form at the study site and expanded later • Field-notes can be typed into the computer later. • Many people do not put field-notes into the computer, they work from their journal.

41. Recording Observations in the field • Write about actual events • Avoid inferences and generalizations • Write down detail • Describe the obvious • Take photographs if you can • Describe actions without evaluating • Push yourself to get details • Write your opinion in separate section • When NOTHING is happening record physical environment in detail

42. Practical field-note taking • Use large margins on the page. This gives space for comments, additional information, evolving questions or theories • Feel free to draw pictures, diagrams and symbols • Write clearly • Feel comfortable where you write field-notes

43. REMEMBER • You need reliable data [FACTS] to be able to generalize • Qualitative research relies upon carefully documented data so that conclusions can be formed

44. Interview transcriptions • Include open-ended questions in the transcription (most formed before the interview) • Include a large margin on the page for comments, quotes, etc. • Write clearly • Word for word transcription is best • Talk and write slowly, if possible • If information is not clear, ask the person to repeat the information before writing it down • Do not summarize information • Record your opinion and thoughts (separately)

45. Observations • Data about the environment, people, events, activities that are under study • Traditions and life-ways of people • ‘Special’ locations or events • Confirm what has been said or not said • Find more key informants • Check accuracy of information gained in interviews and social mapping • Provide information previously unknown • Develop relationship with participants • Provide additional data

46. Key pointswhen making observations • Begin with informal conversation • Then introduce the project • Obtain consent to take notes • Explain the purpose of note taking and getting more detailed data • Identify key informant or additional key informants • Take in-depth field notes of observations

47. Free-list and rating • Simple, yet powerful research method • Generally used to study a cultural domain • Everyone knows the same free-list, example, diseases, plants, occupations, health workers • Easy to develop & analyse • Enjoyable • Compliments other research methods, especially social mapping and interviews

48. Key points when making free-list • Ask informants to list all the people who provide care when they are sick (plus, those that come into the village and those outside) • Ideal to have (15) or more free-lists from the same study site (good sample for analysis) • Analyse free-lists by: • Order and frequency of recall • Gender • Age • Occupation / practitioner • Location

49. Using free-lists • Opening technique to obtain information to use in interviews • Probe local terminology • Explore ‘special’ terminology • Explore cultural and social domains • Inform programs

50. Rating free-lists • Produce ordinal data • Easy to administer • Combined with interviews they are powerful data generators • Used in a variety of research settings • Useful when exploring many subjects, eg, foods, diseases, health seeking practices, and so on