1

QUALITATIVE RESEARCH

Jane Buxton MBBS MHSc FRCPC Professor and MPH Practicum Director –SPPH Harm reduction lead BC Centre for Disease Control

October 5th, 2015 Fundamentals of Scholarship MDUP Year 1.

Faculty Disclosure -Jane Buxton • Relationships with commercial interests

• No grants • No honoraria • No consulting fees

• Employed full-time by UBC/BC Centre for Disease control

2

Learning objectives a. Discuss the principles and roles of qualitative research b. Describe the forms of qualitative research

3

Outline • What is qualitative research? • Why do qualitative research? • Comparison qualitative vs. quantitative • Qualitative research methods

• Key informant interviews and focus groups • How to perform the research and analysis • Examples

• Walk through an example - Youth Injection Prevention Project

4

Until you move to your sites: Elise associate.dean@ubc.ca 604.875.4111, 61979 MDUP student resources, Counselling & Support: http://mdprogram.med.ubc.ca/student-resources/student-counselling-and-support/?login UBC Student Health Services UBC Wellness Centre (SUB) UBC Student Counselling Services Physician Health Program of BC

How do you contact Student Affairs?

What are qualitative methods? • Quantitative methods generates numbers, data that is

measured (quantity)

• Qualitative methods provide descriptions, non-numeric data (quality)

6

Class of 2019

Qualitative • Room almost full • Young men and women • Friendly & attentive • Good looking group

Quantitative (2018)

• 288 students • 56% female • Mean age = 24 years • 42% prev. attended UBC

7

Why do qualitative research?

• Use in complex situations with a need to describe and understand people - their beliefs, behaviours, practices and interactionsi

• Terminology: • to explore • gain an understanding • provide insights • inform…..

• Helps us to understand ‘The why’

8

I Wright JG, McKeever P. Qualitative research: its role in clinical research. Ann R Coll Physicians Surg. Can 2000 33:275-80

9

Why do qualitative research cont..? • Supplement quantitative work (MM) week 9

• Illuminate results of quantitative study • Exploratory phase of research e.g. to inform quantitative survey

• Play an important role in facilitating the dissemination of research findings

Equality vs. Equity 10

Source: Many versions on web; This image was adapted by the City of Portland Office of Equity and Human Rights from the original graphic: http://indianfunnypicture.com/img/2013/01/Equality-Doesnt-Means-Justice-Facebook-Pics.jpg

Challenges of Access to health care

Concept Examples Availability • Lack of regular care provider

• Wait times Accessibility • Geography

• Rural areas less clinics e.g. methadone treatment Accommodation • Hours of clinic operations

• Are outreach and mobile clinics available? Affordability • Prescription costs

• Cost of travel • Lost work to attend

Acceptability • Culturally appropriate • Languages offered/translators • Perceived stigmatizing staff

11

12

Photo credit: Oxfam East Africa

Why is the well not used? • Use qualitative methods – observe and interview villagers

• to explore … • gain an understanding … • provide insights .. how to address • inform….. so can learn for the future

• Women do the washing and collect water • Well is in opposite direction to the river • Well is exposed – no shade • Cultural beliefs • Elder has advised not to use it • No community champion

13

14

Comparison of research approaches

• Quantitative • Objective • One reality • Reduction, control,

prediction • Measureable • Report statistical analysis • Researcher separate • Context free

• Qualitative • Subjectively valued • Multiple realities • Discovery, description,

understanding • Interpretive • Report rich analysis • Researcher part of process • Context dependent

15

Qualitative Research Methods • Ethnography • Narrative Analysis & Life History • Participatory Action Research

• In-Depth Interviews (key informants) • Focus Groups

• Or combination

16

Ethnography “Ethnography is the classic method for studying a social or cultural niche about which we know very little” Daly et al., 1997

• Systematic study/observation of people and cultures in their natural setting- participant observationi

• Researcher can’t control what happens in the field

• Provides a detailed in-depth description of everyday life and practice; sees world from others perspective

• Long term engagement in field setting - typically months/years (time consuming/costly)

i. Brian Hoev: http://www.brianhoey.com/General%20Site/general_defn-ethnography.htm

17

Narrative Analysis & Life History

• The study of people’s stories that involves creating, collecting, & analyzing written texts, videos etc

• Attention to structure of narratives as a whole • e.g. women on prison research

team “write about their substance of choice/addiction”

18

Participatory Action Research (PAR); Community Based Research

• Gives voice & aims to produce knowledge from the point of view of marginalized groups

• Equal power in controlling the research • Attempts to combine research, education, and action in a single endeavor

BUT • Data Ownership • Time Consuming • Wide range of skills required

More to come week 10 FoS

19

Qualitative Research Methods • Narrative Analysis & Life History • Ethnography • Participatory Action Research

• In-Depth Individual Interviews (key informants) • Focus Groups

• Or combination

20

In-depth key informant interviews • Key informant interviews ‘experts’

• Persons using or providing the service or both • Sensitive topic - uncomfortable disclosing in a group • Choose setting for the individual

• Logistics • Face to face or on phone/Skype • Obtain informed consent; Collect demographics • Token of appreciation

• Travel reimbursed • Honorarium - for expertise, loss of income generating activities;

cash vs. tokens. • For professionals/students – draw for iPad, coffee card

• Open ended/semi-structured interview guide • Usually 30mins- 1 hour; sometimes longer

21

Ex. Key informant interviews

Harm reduction: policy of supply distribution1

Heard from clients not able to get clean needles when needed

To determine what happens on the ground - in person interviews with service providers across BC

Blue lights in public washrooms discourage IDU2 • What is the effect of blue lights in washrooms on people

who inject drugs (PWID) • Interviews with current/former PWID re perceived harms

and benefits of blue lights

22

Focus group

• Enable in-depth discussion (1-1.5 hours)

• Small number of people (6-10) • Comfortable/familiar setting, provide food • Collect demographics (forms/hat etc) • Reimbursement – travel; honorarium cash/tokens • Empowering for marginalized groups • Interactive, but maybe influenced by an individual

• Participants have shared socio-cultural background, experience, or area of concern

23

Focus group

• Obtain informed consent - warn re limited confidentiality • Pseudonyms/name tags

• Ground rules re confidentiality, respect, expectations

• Moderator introduces topic/facilitates discussion • Facilitator maybe person with experience – connects with

participants

24

Advantages FGI

• Explores in depth knowledge of participants more quickly and less $ (vs. interviews)

• Marginalized groups; Empoweringi (Ex. PEEP)

• Flexible nature allows for discovery of potentially invaluable information

• Interactive nature provides valuable insights • Increased comfort level • Reduces misunderstanding of research question

i (Kitzinger 1995; Litosseliti 2003)

Sampling participants • Ensure diversity; variety of perspectives • Doesn’t need to be representative • Be clear on inclusion/exclusion • Enrolling

• Referred by clinic staff; • Experiential person e.g. board member VANDU • Sign up list at agency • Use snowball sampling • Purposive sampling

• Collect demographic information so can report on participants

• Need ethics approval

25

26

Ex. Focus groups

Perceptions of crack use and how people reduce harms 3

Different geographic areas, sex spec. groups

What do people with hepatitis C want in their care provision4 FGI persons referred to Public Health HCV

clinics around the province

The Caravan – priorities of PWUD FGI 17 communities around the province

27

Question(ing) guide FGI and KI • Used to direct conversation, ensure cover topics

• Based on lit review, previous experience • Ensure open ended questions allow sharing

• Pilot with population- language, terms esp. drugs

• Order topics – more sensitive last, you or someone you know….

• Be flexible and ready to redirect if off topic “Thank you for sharing, that’s really interesting;–I’d be interested to hear if others feel the same”

• Guide is not static; discuss/review after interviews • Assess question flow; overall perspective • ‘Saturation’ –no new information, same response • Flush out topics mentioned but not explored

28

Data collection

• Note taking • Flip chart (FGI) • Audio tape

• +/- transcription

• Video taping • Field notes • Research diary

• Bracketing - admit your a priori biases/ perceptions

29

Analysis

• Synthesize and make sense of data to identify patterns, themes etc.

• Iterative process

30

Analysis

• Research team or individuals review notes and transcriptions (verbatim) • Ensure personal identifiers removed • Identify areas need clarity /listen to tape • Team / 2 people read through (some/all) • Identify some broad themes • Categories / codes • Identify salient quotes which fit with themes and categories

Problems using harm reduction sites? 1. “I can’t get to the clinic during the times its open - it’s only open 8:30 to 4:30” 2. “The only place I can get supplies from is 20 miles from where I live and they will only give me 25 needles at a time.” 3. “They take one look at me and tell me to wait outside the building” 4. “When I ask for needles they thrust them in my hand to get rid of me quickly. I don’t get a chance to ask the nurse about my arm infection” 5. “The clinic isn’t open at weekends and they don’t give me enough to last till Monday so I have to reuse my needles or borrow from friends.” 6. “The girl on reception doesn’t say hello or look me in the eye when she speaks to me” 7. “I can understand they prefer to work with clean mums and babies and don’t want drug users contaminating them”

32

Analysis • Using hard copy transcription or notes

Make notes in margin Identify meaning unit Highlight text in different colours Cut out and move on floor

• Use software e.g. Nvivo, Atlasti organize and manipulate data/quotes, photos, videos etc

• Coding by at least 2 people, discuss and come to consensus (reduces bias)

• May use/adapt an existing framework

33

Use an existing framework

HCV Quality of care4 Donabedian framework for evaluating health services:

structure / process / outcome

34

Quality of HCV care from the patients perspective4

Quality of HCV care from the patients perspective – concept mapping4

• 6 of top 8 – communication • Specialist/nurse is honest

with me • Specialist/nurse doesn’t

talk down to me • Specialist/nurse listens to

me

35

Harm reduction: policy of supply distribution - findings1

• Some sites still use needle exchange • Thought would reduce needle litter in community

• Identified need for more explicit guidelines • Share evidence re why distribution with safe disposal is best

practice • Reduces HIV transmission

• Reduce needle litter • Involve peers locally in needle pick up • Increase availability safe disposal boxes • Personal disposal containers

36

37

Blue light study2 • Blue lights in public washrooms to discourage IDU

• SDPO project 2010/11 Crabtree A, Mercer G, Horan R, Grant S, Tan T.

• Methods: • Interviewed 18 current/former PWID • Transcribed verbatim; used Nvivo to organize data • Interpretive description- concept categories clustered into

overarching themes • Results: identified significant harms and limited benefit

• i) vein damage; ii) seek next dose sooner; iii) look for other places to inject less safe/hygienic; iv) more likely visible to police and public

But many favoured blue lights in washroom believing their own health and safety is less important than preventing harms to the public – internalized stigma

Caravan – identified 8 priorities 1. Improve interactions with health professionals "The hospital won't let you in if you're a drug addict. They put you to the back of the list... You have to be dying to get in."

2. Promote access to a range of housing options “…even if you're trying to get clean. You're in a situation where all of your neighbors are using because there's nowhere else that will rent to you."

3. Improve treatment by police "The police always harass you, pull up on you, ask you what you're up to, even if you're just sitting there."

38

Caravan – identified priorities cont. 4. Ensure harm reduction best practices are followed everywhere "You give back your rigs and you get another one, but they don't give you enough. They only give five needles and they're closed weekends.”

5. Connect with illicit drinkers “…they have a safe injection site in Vancouver … They should have a building for people who drink outside, so they can be safe inside"

6. Improve social assistance "As soon as dentists figure out you're on social assistance, they don't want to see you.“

39

Caravan – identified priorities cont. 7. Support user-run organizations

"It's powerful to gather. I've never heard the words 'drug war survivors‘ before – I'm walking out of here today taller than when I walked in.“

8. Engage with and encourage allies “.. this one clinic, they'll assist you if you have an abscess. They'll lance it right there. They won't look down on you. They're developed from an Aboriginal point of view. At the hospital it's terrible – white people are always the first to get treated, you have to wait for six hours because they push you right aside, and if you need painkillers they won't give it to you because they think you're a drug user.”

40

Caravan – great things emerged 1. Eastside Illicit Drinkers Group for Education (EIDGE) was formed

41

Caravan – great things emerged 1. Eastside Illicit Drinkers Group for Education (EIDGE) was formed 2. Provincial harm reduction committee

• Offers annual funds in each regional health authority to support peer led initiatives

• Invites peers to annual meeting • Developed ‘how to involve people who use drugs’ • Research project- develop best practice guidelines for

health authorities/agencies to engage peers in planning, policy, research and evaluation.

42

43

44

Validation

• Iterative process - does the next interview fit with the themes and model

• Mixed methods and Triangulation • Member checking

• Taking it back – same, similar, or CAB

45

Youth Injection Prevention project5

Aim • To identify what prevents street-involved youth from

transitioning into injection drug use

46

Methods • Who should we interview? • How? (one-on-one interviews, focus groups) • Who should facilitate interviews? • How should we develop questions?

47

Methods • Interviews with service providers • Both- FGI and interviews with youth • Trained youth to facilitate focus groups • Developed questions with youth researchers

• Share your own experiences or those of someone you know

• Youth Researchers practiced & tweaked the question guide • Sites identified by collaborators

• Diversity e.g. LGBTQ; Aboriginal • Put up posters / sign up sheets

48

Ongoing review of data/debrief • Aim: to illicit resiliency/protective factors

• But heard about risks • General negative perspectives • Youth eager to leave FG

• Reworded questions and prompts • “What are some positive things in a youth’s life that help them not

to inject?”

• Much more positive • Almost therapeutic • Youth happy to stay longer

49

50

Training, team building, debriefing

Coding

51

HTTP://WWW.SCIVEE.TV/NODE/36248

Qualitative research can play an important role in facilitating the dissemination of research findings

Outline • What is qualitative research? • Why do qualitative research? • Comparison qualitative vs. quantitative • Qualitative research methods

• Key informant interviews and focus groups • How to perform the research and analysis • Examples

• Walk through an example - Youth Injection Prevention Project

52

53

References

1. Buxton JA, Preston E, Mak S, Harvard S and BC Harm Reduction Supply Services Committee. More than just needles: An Evidence-informed Approach to Enhancing the Distribution of Provincial Harm Reduction Supplies. Harm reduction Journal (2008), 5:37 http://www.harmreductionjournal.com/content/5/1/37

2. Crabtree A, Mercer G, Horan R, Grant S, Tan T, Buxton J. A qualitative study of the perceived effects of blue lights in washrooms on people who use injection drugs. Harm Reduction Journal (2013) 10:22 http://www.harmreductionjournal.com/content/pdf/1477-7517-10-22.pdf

3. Persaud S. Tzemis T, Kuo M, Bungay V, Buxton JA. Controlling Chaos: the perceptions of crack cocaine users in Vancouver. Journal of Addiction, (2013) Article ID 851840 http://www.hindawi.com/journals/jadd/2013/851840/

4. Brunings P, Klar SA, Butt G, Nijkamp MD, Buxton JA. “It's a big part of our lives." Defining Quality of Hepatitis C care from Patient's Perspective: A Qualitative study." (2013). Gastroenterology Nursing 36(4)249-257

5. Tozer K, Tzemis D, Amlani A, Coser L, Taylor D, Van Borek N, Saewyc E, Buxton JA. Reorienting risk to resilience: Street involved youth perspectives on preventing transition to injection drug use BMC public health (2015) http://www.biomedcentral.com/1471-2458/15/800