Download Chapter 2: Planning a Qualitative Study

CHAPTER TWO
PLANNING AN APPLIED QUALITATIVE STUDY
This chapter outlines the various activities involved in planning an
applied qualitative drug use study. Following a brief section on the
need for a resource person when applying these techniques, the
chapter describes the major steps involved in implementing a
study. It concludes with a summary of common implementation
problems.
2.10: Is There Need For a Resource Person?
The information provided in this manual is designed to enable investigators to be as self
dependent as possible. However, health professionals typically do not have training or
experience in using applied qualitative methods. In many cases, it will be necessary for such
people who intend using this manual to seek assistance from someone familiar with these
methods. How much assistance is needed will depend upon the previous experience of the
investigator(s), personality skills, the size of the study, and the resources available to it.
When considering using the services of a resource person, look for someone who:
!
analyses situations critically;
!
recognizes and avoids bias;
!
is socially sensitive to others= feelings;
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possesses good powers of observation;
!
has good interactional qualities.
Where might you find such a resource person? These skills are traditionally associated with
social scientists in such disciplines as anthropology, sociology, psychology, or communication
studies. However, training alone is not as important as experience in actually using applied
qualitative methods in the field. In practice, such people are often not easy to come by,
especially at the district level in most countries. If they are available at all, they may be much in
demand and the resources for engaging them may be limited.
Apart from social scientists, you could also look for health or medical colleagues who have had
training in public health and some experience using similar techniques. Sometimes social and
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community workers with experience in research could prove equally useful.
The assistance of an experienced resource person is likely to be
necessary if you have no previous training and experience in using
applied qualitative methods. It is advisable to find such a resource
person before using these methods for the first time.
2.20: Steps in Planning an Applied Qualitative Study
The recommended steps in implementing an applied qualitative study are:
STEPS IN PLANNING AN APPLIED QUALITATIVE STUDY
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
2.21.
Form a Working Group
Identify a Specific Problem
Formulate Specific Questions
Choose a Package of Study Methods
Identify Study Groups
Plan for implementation
STEP 1: Form a Working Group
One important decision in the early stages of a study is to determine who will be involved in
planning and implementation. The success of the study depends to a large extent on the calibre of
those who will be involved in implementing it.
a.
Multidisciplinary Study Team
There are no formal criteria for determining who should be involved. This will vary with the
aims and purpose of the study. Nevertheless, as mentioned above, it is ideal if co-investigators
have had training and experience in a relevant field. If not, assistance of an experienced resource
person should be sought before using these methods for the first time.
One excellent strategy is to form a multi-disciplinary team. Ideally, such a team would involve
medical and para-medical personnel as well as social scientists. In addition, it may be helpful to
include policy makers, planners, and others who are likely to benefit or implement the results of
the study. Clearly, if a resource person will assist in implementing the methods, it would be
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appropriate to include him or her as a member of the multi-disciplinary team.
The role of the study team is to make major decisions regarding planning and implementation.
Using their individual expertise and joint experience, the team can assist in keeping the study
focussed on relevant issues, and drawing insights from the findings.
b.
Field Staff
Usually, field staff will be recruited to collect data. Teachers, nurses, pharmacists, and other
health staff often prove to be good and reliable data collectors. When selecting the members of a
field team, some of the essential qualities to look for include:
!
familiarity with the culture of the people being studied;
!
ability to establish rapport and gain confidence and trust;
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knowledge of health care system and drug use terms;
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ability to speak the local language;
!
ability to listen well.
Depending upon the study situation, one or more of the following categories of field staff may be
required:
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Supervisor(s): to coordinate field work, monitor the performance of interviewers
or other field staff, and assure the quality and consistency of data collection.
!
Moderator: to facilitate focus group discussions.
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Interviewers: to guide respondents from topic to topic and record responses in indepth or structured interviews.
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Observers: to observe and encode as much as possible events, situations, or
behaviors according to a pre-defined protocol.
!
Recorders: to take notes about the topics discussed by respondents in a manner
that will not affect the flow of a discussion as a non-participant observer.
!
Assistants: to assist focus group moderators or interviewers to run sessions
smoothly, especially when interference from crowds and children must be
avoided.
!
Translators: to translate for respondents or transcribe responses where field staff
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and respondents do not speak a common language.
!
Administrative Personnel: to handle administrative business and finances
related to the study.
2.22. STEP 2: Identify a Specific Problem
Every study begins with the recognition of a problem. The first task in a study is to identify and
state explicitly the problem to be investigated.
a.
What is a study problem?
A problem is a perceived difficulty or an observed discrepancy between what should be and what
is. "The problem" is important to every study since it will guide the specific questions that must
be raised by the investigator.
Examples of problems that could be addressed in an applied qualitative study might be:
!
a high proportion of patients in public health facilities receiving injectable
vitamins and analgesics;
!
continuing use of antidiarrheals in children among private practitioners;
!
high frequency of antibiotic use for primary care patients with upper respiratory
infections;
!
greater use in hospital outpatient departments of nonsteroidal anti-inflammatory
drugs than aspirin or paracetamol.
Some key principles to keep in mind when selecting a problem to investigate in an applied
qualitative study are:
b.
!
the problem should be important, either clinically or economically;
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the problem should be focused and specific;
!
there should be some uncertainty about the causes of the problem or the way to
address it most effectively.
Background Information
After you specify the problem, it is a good idea to review what is already known about it. This
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helps to guide the subsequent investigation, prevent duplication, and suggest appropriate
questions that need to be answered. Useful sources of background information are reports of
previous and other related studies on this topic, clinical records or administrative data, or
educated opinion consisting of published and unpublished papers and articles. Such information
may be available from the ministry of health, the drug regulatory agency, international
organizations, drug companies, or private organizations involved in health care.
2.23. STEP 3: Formulate Specific Questions
The objective of the types of studies we describe in this manual is to provide the information
needed to design an intervention. Once a problem has been identified, it is useful to narrow the
focus of a study to a limited set of questions that may influence what kind of intervention is
selected.
It is helpful to plan and formulate questions in a structured way in order to make sure that no
aspects of the problem or study topic are missed. For example, the case study from Pelotas,
Brazil (Table 2.1), shows how one team developed a set of questions to guide an applied
qualitative research study before undertaking an intervention to improve diarrhea treatment.
Your task at this point is to develop a similar set of questions to guide your own study. The
questions should seek to explore the problem you have identified in more depth. For
example, they might examine aspects of the local social, cultural, or economic environment
that influence the problem selected. They might seek to explore beliefs, attitudes, or
misconceptions of health workers or patients related to the problem. When developing
these questions, consider brainstorming with those in authority and other influential
persons or groups in the potential target population to learn more about the way they think
about the problem at hand.
The following are some examples of the kinds of questions that may be answered about
drug use behavior in most health care settings using applied qualitative methods. The
questions are all designed to provide useful information for selecting the type of
intervention that might be effective, or for targeting the intervention to particular
individuals or behaviors. The questions have been arranged in the structured format
followed in the Brazil case study.
CASE STUDY: IMPROVING DIARRHEA TREATMENT IN PELOTAS, BRAZIL
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A health center record review in Pelotas, Brazil, found specific problems in diarrhea treatment in children under five. Prior to
launching an educational intervention for physicians to improve practices, the study team used patient exit interviews,
physician and patient in-depth interviews, and observations of treatment episodes to answer the following questions:
To Describe the Problem in Greater Detail
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Are treatment practices the same in health centers managed by the municipality, university, and state
government?
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Is inadequate knowledge about diarrhea or its treatment a common problem among physicians and patients?
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What knowledge deficits exist about the causes and diagnosis of diarrhea? About the need for ORS? About
the dangers of specific anti-diarrheas? About the efficacy of antibiotics or anti-parasitics?
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How do physicians think other physicians manage diarrhea?
To Decide if an Intervention is Feasible
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How much do patient expectations influence physicians' treatment choices?
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How satisfied are patients with different kinds of treatment for diarrhea?
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How important is maintaining patient satisfaction to physicians?
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Do physicians feel that patients are capable of learning if the effort was made to explain about diarrhea and
its treatments to them?
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Would physicians or other staff members have time for counseling patients about diarrhea or other health
problems?
To Target the Intervention
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How often do mothers ask directly for specific types of treatment?
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Are there non-verbal ways that mothers influence physician decision-making?
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How do physicians respond when asked for certain treatments?
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Do physicians feel a group identity with colleagues at the health center?
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To which respected peers do physicians turn with questions about treatment?
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How often do physicians approach colleagues with medical questions?
To Define Specific Intervention Messages
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How important to physicians is the self-image of being a knowledgeable scientist or powerful healer?
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When physicians have changed their practices in the past, what has stimulated them to do so, and how do
they feel about these changes?
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What do physicians think about prototype materials developed to promote correct diarrhea practices?
To Decide Format and Style of the Intervention
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How do physicians get information about new health problems or drugs?
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Do they ever attend continuing education sessions, and are they useful?
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Do they read any journals and which ones?
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Do they learn about drugs from drug package inserts, advertisements, or drug company representatives, and
is this information valuable?
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How do physicians respond when presented with summaries of the practices of their health center in relation
to all similar facilities?
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How do physicians feel about different models for continuing education: group seminars, visits by medical
experts, visits by pharmacists?
a.
To Describe a Problem in Greater Detail
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Do practices vary greatly by location, health facility, or health provider?
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b.
c.
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Do deficits in knowledge contribute to problem practices?
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What specific areas of knowledge are deficient: diagnostic procedures, drug
efficacy, drug dosing, etc.?
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Do health providers think their practices are the same as or different from
their peers?
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Do problem practices vary by diagnosis, type of patient, time of month, etc.?
To Decide if an Intervention is Feasible
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What is the communication like between patients and health providers?
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How often do patients express a preference for a certain drug or type of therapy?
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How satisfied are patients with the care they receive?
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What specific aspects of care contribute to patient satisfaction?
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How important is satisfying patients to health providers?
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Do health workers try to educate patients about their illness or the drugs they
prescribe?
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Are there severe constraints in the work environment that would prevent health
providers from changing their behavior?
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Are there proper drugs available at all times?
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Are health providers interested in improving their practices?
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Are the administrative authorities supportive of the types of changes proposed?
To Target the Intervention
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Are there particular health providers or facilities with especially poor practices?
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What is the relationship between an individual provider and the group in which he
or she practices?
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Are there features of the social, cultural, or behavioral context that could be used
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to influence the practices of individual health workers or patients?
d.
e.
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Are there particular people whose opinion is especially influential with health
providers?
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Would it be possible to recruit these opinion leaders to assist in implementing the
intervention?
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Is it possible to reduce the general problem of interest to more specific behaviors
or practices that it would be easier to change?
To Define Specific Intervention Messages
!
Can specific myths about practice be identified that it is possible to debunk with
scientific facts?
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Are there specific areas of miscommunication between patients and health
providers that can be highlighted in an intervention?
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What kinds of educational materials are available to health providers or patients?
!
When health providers or patients have changed in the past, what was it that
caused them to change?
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How do health workers or patients respond to prototype intervention materials?
To Decide Format and Style of Intervention
!
What sources of information do health providers use to learn about health
problems or drugs?
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What educational programs have health workers already attended?
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What model of continuing education is most highly rated: group seminars,
workshops, visits by medical experts, etc.?
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How often do health workers interact with drug company representatives?
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Is information from drug companies considered to be biased?
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Do health workers have access to any unbiased sources of drug information?
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Are there any ways for health workers to review their practices for the problem of
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interest: regular utilization reports, practice audits, departmental reviews, etc.?
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How do health workers respond when given summaries of their own practices?
2.24. STEP 4: Choose a Package of Study Methods
Once the study questions have been specified, you are ready to determine what methods will be
suitable to answer these questions. When deciding which methods are most appropriate, there
are a few general issues to consider.
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The nature of the problem, and the amount of information needed to choose
among alternative intervention strategies;
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The resources needed to gather, process, and analyze the data;
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The time frame available to carry out and complete the study;
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The local research capacity to carry out and complete the study;
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The feasibility of implementing each method in the specific local environment,
taking into account attitudes, logistics, and time frame.
Assuming that resources and capacities are not a serious constraint, then the selection of methods
is based on their advantages and disadvantages (see Table 1.1 and Section 1.13). Each method is
best suited for answering different types of questions. The methods chosen should reflect the
questions to be answered for a particular study. It is often best to explore a given question by
more than one method.
For example, Table 2.1 describes the set of study questions selected by the team in Pelothas,
Brazil, that was investigating reasons for inappropriate diarrhea treatment in public health
centers. They settled on a package consisting of (1) patient exit interviews using structured
questionnaires; (2) in-depth interviews with a sub-sample of these patients scheduled at a later
time; (3) in-depth interviews with a sample of physicians working in the health centers; and (4)
structured observations of 5-10 diarrhea cases treated by each physician.
The brief exit interviews were used to answer questions about patient knowledge and
satisfaction. The long in-depth patient interviews explored attitudes and beliefs about diarrhea in
greater detail, and investigated willingness to change treatment. Physician in-depth interviews
provided detailed information about knowledge, attitudes, peer relationships, and sources of
information. Focus groups were not used because of concerns about the logistics of assembling
groups of doctors. Structured observations were used to learn about patient-doctor
communication, and diagnostic and treatment practices.
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2.25. STEP 5: Identify Study Groups
One basic decision in any study is how to identify the study population. It is important that
the sampling procedures are clearly determined at the beginning of the study since the
quality of information will depend to a large extent on the choice of respondents.
In drug use studies, the study units may be patients, prescribers in health facilities,
providers in communities, and many others. Correct sampling involves the selection of a
study group that is representative of the study population. Such a group has all the
important characteristics of the population being studied. Incorrect sampling, that is,
selecting a group that is not representative, can seriously bias study results.
Sampling procedures can be categorized into probability and non-probability methods.
Probability sampling methods are generally appropriate for quantitative studies, where
there is a large population of interest, and random selection methods are used to choose the
members to include in a study. Of the methods discussed in this manual, probability
sampling would usually only be used for large questionnaire surveys (or perhaps a large
survey of structured observations involving a number of health providers). Some of the
methods for probability sampling are introduced in Annex A.
Non-probability sampling is not based on a list of all the possible members of a study
population, also known as a sampling frame. Instead, study members are chosen
purposively, with an eye to representing the population in a certain way, or according to
quotas.
The key issue in drawing samples for applied qualitative research is being sure to gather
information about all the important subgroups in the population. For example, in a study
to look in more depth at ARI treatment practices, it may be important to look separately
at: practices of para-medics vs. physicians; practices in rural vs. urban facilities; practices
for children under five vs. older patients. This would mean including enough people from
each of these subgroups to be able to compare and contrast them.
How many people are enough? For in-depth interviews and focus groups, the objective is
to get a general idea of the practices, beliefs, opinions, etc. in each important subgroup in
order to be able to target the intervention appropriately. If there are consistent results, this
would mean that only aout two focus groups per subgroup, or 3-4 in-depth interviews,
would be needed. If the results in a subgroup are inconsistent, then additional focus
groups or interviews would be conducted until the reasons for inconsistency are
understood.
For structured questionnaires (and sometimes for structured observations), a larger sample
is required in order to generate quantitative summaries like percentages or averages. In
these cases, a good general rule is to include 25-30 members in each important study
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subgroup, For example, a study might compare 25-30 urban health workers with an equal
number of their rural colleagues. More detail about sampling is included in each of the
following chapters describing the individual methods.
2.26. STEP 6: Plan for Implementation
The final step before embarking upon the work is to map out the sequence of how various
activities will proceed. This will require attention to the following activities:
a.
Choose Site(s) and Location(s) to be Used for the Study
The specific geographic areas and health facilities need to be identified, keeping in mind the need
to represent the larger population. Visit sites to become familiar with the people and logistics.
This visit also provides an opportunity to arrange and prepare for subsequent activities including:
!
Obtaining the necessary permission for the study from concerned
authorities/people in the community.
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Identifying how study participants will be selected.
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Locating and arranging sites for group discussions and interviews when necessary.
!
Obtaining basic descriptive information about the area/facility.
!
Recruiting any support staff in the community that may be needed.
In addition, the visit will afford an opportunity to decide the date and time for implementing
individual methods. Consider the activities of the group or the community and their schedules
before this decision is made.
b.
Select Coordinators for Each Study Component
If the study will include multiple methods, it may be advisable to identify coordinators for each
method. These coordinators will be responsible for identifying field staff, training them for their
specific tasks, supervising the field work, and preparing the data for analysis.
c.
Plan the Schedule for Individual Study Components
Some studies using multiple methods will implement all methods at the same time in the same
sites. The plan for this type of study requires coordinating roles within each study team and
scheduling the work of study teams within the selected study population (see Table 2.1).
COMPOSITION OF STUDY TEAMS
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Team No. 1:
1.1
1.2
1.3
In-depth
In-depth
FGD
(Administrator)
(Medical Officer)
(Mothers)
1.4
1.5
Intercept
Observation
(Mothers)
Dr. Mannan
Dr. Mannan
Dr. Shamsun Nahar (Moderator)
Dr. Faisal (Note-taker)
Ms. Panna
Dr. Mahamud
Team No. 2:
2.1
2.2
2.3
In-depth
(Administrator)
In-depth
(Medical Officer)
F G D (Mothers)
2.4
2.5
Intercept
Observation
(Mothers)
Dr. Iftikar
Dr. Iftikar
Dr. Khadiza (Moderator)
Mr. Matin, Dr. Jamal (Note-takers)
Dr. Khadiza
Dr. Rashid
FIELD VISIT SCHEDULE
Date
26.07.92
Sunday
Place of Visit
(1) Sonargaon THC Team 1
(2) Gajaria THC
Team 2
27.07.92
Monday
(1) Bhaluka THC
(2) Sreepur THC
Team 1
Team 2
29.07.92
Tuesday
(1) Dhamrai THC
(2) Uthali THC
Team 1
Team 2
Some studies may require one applied qualitative method to be completed before another can
begin, for example, if focus groups are being used to develop specific items that will appear in a
later questionnaire. Another example would be if patient-physician observations needed to take
place before in-depth interviews with physicians were carried out to avoid biasing physician
behavior during the observations. The timing, sequencing, and coordination of components
should be organized in the overall study schedule.
After completing a schedule of study components, it is time to shift to the steps needed to
implement each applied qualitative method. These steps are covered in detail in each of the four
chapters which follow.
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