Sampling for qualitative research

The probability sampling techniques used for quantitative studiesare rarely appropriate when conducting qualitative research.This article considers and explains the differences betweenthe two approaches and describes three broad categories of naturalisticsampling: convenience, judgement and theoretical models. Theprinciples are illustrated with practical examples from theauthor's own research. Keywords. Qualitative sampling.     

Integration of midwives into the Quebec health care system. L'Equipe d'Evaluation des Projets-Pilotes Sages-Femmes

This paper reports on one aspect of the evaluation of the midwifery pilot projects in Quebec: the identification of the professional and organizational factors, as well as the mode of integrating midwives into the maternity care system, that would promote the best outcomes and the autonomy of midwives. The research strategy involved a multiple-case study, in which each midwifery pilot project represented a case. Based on a qualitative approach, the study employed various sources of data: individual interviews and focus groups with key informants, site observations and analyses of written documents. Results show that midwives were poorly integrated into the health care system during the evaluation. Four main reasons were identified: lack of knowledge about the practice of midwifery on the part of other health care providers; deficiencies in the legal and organizational structure of the pilot projects; competition over professional territories; and gaps between the midwives' and other providers' professional cultures. Recommendations are provided to facilitate the integration of midwives into the health care system.     

Qualitative methods in general practice research: experience from the Oceanpoint Study

BACKGROUND: The Oceanpoint Study is a collaborative study between generalpractice and medical anthropology. METHOD: The study involved a qualitative ethnographic approach includinglong-term participant observation, in-depth interviews, healthdiaries and focus group discussions. Qualitative methods aresuited to describing the phenomenological perspectives of peoplethrough the generation of rich detailed accounts which leaveparticipants' perspectives intact. RESULTS: The use of these methods in this study has enabled the researchersto explore a range of community beliefs and practices concerninghealth and illness. The underlying concerns and approach ofgeneral practice medicine are similar to those of the qualitativeresearch tradition. CONCLUSIONS: The experience of being a general practitioner parallels theexperience of an ethnographer conducting qualitative researchand the paper explores the similarities and differences betweenthem and discusses the usefulness of such collaborative research. Keywords. Qualitative methods, ethnography, general practice research.     

Healthy Islands in the Western Pacific--international settings development

OVERALL ASSESSMENT AND FUTURE DEVELOPMENTA national framework for action Future development FOOTNOTESREFERENCES     

Introduction of New Vaccines: Decision-making Process in Bangladesh

The understanding of the decision-making process in the introduction of new vaccines helps establish why vaccines are adopted or not. It also contributes to building a sustainable demand for vaccines in a country. The purpose of the study was to map and analyze the formal decision-making process in relation to the introduction of new vaccines within the context of health policy and health systems and identify the ways of making decisions to introduce new vaccines in Bangladesh. During February-April 2011, a qualitative assessment was made at the national level to evaluate the decision-making process around the adoption of new vaccines in Bangladesh. The study population included: policy-level people, programme heads or associates, and key decision-makers of the Government, private sector, non-governmental organizations, and international agencies at the national level. In total, 13 key informants were purposively selected. Data were collected by interviewing key informants and reviewing documents. Data were analyzed thematically. The findings revealed that the actors from different sectors at the policy level were involved in the decision-making process in the introduction of new vaccines. They included policy-makers from the ministries of health and family welfare, finance, and local government and rural development; academicians; researchers; representatives from professional associations; development partners; and members of different committees on EPI. They contributed to the introduction of new vaccines in their own capacity. The burden of disease, research findings on vaccine-preventable diseases, political issues relating to outbreaks of certain diseases, initiatives of international and local stakeholders, pressure of development partners, the Global Alliance for Vaccines and Immunization (GAVI) support, and financial matters were the key factors in the introduction of new vaccines in Bangladesh. The slow introduction and uptake of new vaccines is a concern in the country. Rapid action on the application of GAVI support and less time taken by the Government in processing the implementation and administrative work may expedite the introduction of new vaccines in future in this country.Key words: Decision-making, Qualitative research, Vaccines, Bangladesh     

Caregiver and community insights on coping strategies used by adolescents living in conflict-affected communities

The aim of this qualitative study was to provide a context-specific understanding of adolescent (10–15 years of age) exposure and coping with trauma from the perspective of mothers/female caregivers and key informants in rural conflict-affected villages. Focus groups were conducted with mothers/female caregivers (4 groups with total participants n?=?26) and interviews were conducted with key informants (n?=?9) in four villages in the Walungu Territory, Eastern Democratic Republic of Congo. Focus group and interview guides were designed to elicit responses by participants on adolescent exposures to trauma and coping strategies. A grounded theory approach was used to identify emergent themes. Mothers/female caregivers and key informants reported use of both cognitive and behavioural coping strategies by adolescents. Cognitive coping strategies included avoidance and trying to forget. Behavioural strategies included self-imposed isolation, risk-taking and social-support-seeking behaviours. Findings indicated community social support was a critical resource for adolescents, particularly for adolescents that did not have adequate support from their family. Supporting positive peer, family and community relationships can help prevent risk-taking behaviours and teach positive coping strategies to break a cycle of violence reported in these communities. Recommendations for gender-specific intervention programming are highlighted.

Abbreviations: DRC: Democratic Republic of Congo; PAIDEK: Programme d’Appui aux Initiatives Economiques; PFP: Pigs for Peace; RFR: Rabbits for Resilience     

Towards the establishment of a new target strategy for WONCA Europe: A key informants study

Background/objective: A few years ago WONCA Europe decided to refine its targets and propose a project aiming to evaluate achievements of the previous strategy for development of the discipline in Europe and to review its core components. This paper reports on the issues of this evaluation. Methods: A questionnaire consisting of two parts and four sections was used. The first and second sections addressed issues concerning the 10-target strategy, while the remaining sections addressed issues concerning the new European definition of general practice/family medicine (GP/FM). All European colleges and associations were invited to identify two key informants to complete the questionnaire. Quantitative and qualitative research methods were used for data analysis. Results: Thirty-two key informants from 19 countries responded to the invitation. The targets for vocational training and mandatory undergraduate education in GP/FM received the largest number of responses for the highest level of achievement. Certain core characteristics were considered highly relevant to the delivery of GP/FM and medical education in Europe. Qualitative analysis identified a number of major issues, such as investment in capacity building, improving quality assurance and performance, legislative and political framework, and support. Identified obstacles included lack of academic infrastructure and research capacity, healthcare system characteristics, political issues, and GP practice issues. Conclusion: At present, WONCA Europe is treading new ground for GP/FM, and the current targets clearly need thorough revision. There is some evidence that the new GP/FM definition fits in rather well with the majority of the research and educational needs of certain European countries.     

Sampling for qualitative research using quantitative methods. 2. Characteristics of GPs who agree to videotaping of consultations

BACKGROUND AND OBJECTIVES: Studies using video-recordings of GPs' consultations have beenimportant in investigating GPs' clinical behaviour. Unfortunately,the characteristics of participating GPs are rarely described,making it difficult to assess how representative they are orhow generalizable the studies' results can be. This paper documentsthe recruitment of 53 GPs to a research project which involvedvideo-recording their consultations to determine how GPs approachthe topic of smoking cessation with patients. METHODS: The Attitudes to Smoking Advice Questionnaire was used to selectGPs with diverse attitudes towards discussing smoking with patients. RESULTS: Out of 123 GPs who were eligible to take part, 53 (43.1%) agreed.GPs who agreed to become research subjects were younger, morelikely to work in teaching or training practices and more likelyto be current members of the RCGP. CONCLUSIONS: When planning studies which utilize video-recordings of GPs'consultations, researchers should give consideration to howthis apparent self-selection by participating GPs could influenceresearch results. Keywords. GPs, research methodology, videotape recordings.     

Methods for quality assessment in general practice

BACKGROUND AND OBJECTIVES: There is now a wide variety of methods available to generalpractitioners who want to engage in quality assessment, qualityassurance, or quality improvement activities in their practices.These methods require some kind of performance review, or atleast the collection of some performance-related data. As intraditional research, the choice of methods depends on whatresearch questions one wants to address. This paper elaborateson some key concepts related to the choice of methods, makinga distinc tion between whether any method actually covers performance(what a doctor does in daily practice) or competence (what adoctor is capable of doing) as well as a distinction betweenwhether a method is direct (patient-doctor contact is observable)or is indirect. METHODS: An overview frame will be presented of the methods most commonlyused for data collection within quality assessment. These methodsare discussed on their validity, reliability, feasibility andacceptability. Direct methods aimed at recording performanceare assumed to hold the highest validity, but practical, economicand logistic factors may favour less ambitious methods for auditor quality improvement activities. CONCLUSIONS: One crucial element in all methods is creating a set of empiricaldata, as a basis for comparisons, reflection, dialogue and discussionsamong colleagues. Keywords. General practice, quality of care, methods, quality assessment.     

Exploring key informants’ perceptions of Covid-19 vaccine hesitancy in a disadvantaged urban community in Ireland: Emergence of a ‘4Cs’ model

AimThe aim of this study was to explore key informants’ views on and experiences with Covid-19 vaccine hesitancy in a Dublin community with a high concentration of economic and social disadvantage and to identify feasible, community-centred solutions for improving vaccination acceptance and uptake.MethodsQualitative, semi-structured interviews were carried out at a local community-centre and a central hair salon. Twelve key informants from the target community were selected based on their professional experience with vulnerable population groups: the unemployed, adults in recovery from addiction, the elderly, and Irish Travellers. Inductive thematic framework analysis was conducted to identify emergent themes and sub-themes.ResultsDrivers of vaccine hesitancy identified by key informants largely fell under the WHO ‘3Cs’ model of hesitancy: lack of confidence in the vaccine and its providers, complacency towards the health risks of Covid-19, and inconvenient access conditions. Covid-19 Communications emerged as a fourth ‘C’ whereby unclear and negative messages, confusing public health measures, and unmet expectations of the vaccine’s effectiveness exacerbated anti-authority sentiments and vaccine scepticism during the pandemic. Community-specific solutions involve the provision of accurate and accessible information, collaborating with community-based organizations to build trust in the vaccine through relationship building and ongoing dialogue, and ensuring acceptable access conditions.ConclusionsThe proposed Confidence, Complacency, Convenience, Covid-19 Communications (‘4Cs’) model provides a tool for considering vaccine hesitancy in disadvantaged urban communities reacting to the rapid development and distribution of a novel vaccine. The model and in-depth key informants’ perspectives can be used to compliment equitable vaccination efforts currently underway by public health agencies and non-governmental organizations.     

The cycle of change: implementing best-evidence clinical practice

To improve health outcomes, effective and systematic mechanismsto foster the adoption of evidence-based guideline recommendationsinto routine practice need to be identified. A cyclical processfor achieving this objective involving three key phases is suggested. Phase 1. Writing actionable best-evidence guidelines that prioritizekey recommendations while indicating the levels of adoptionneeded for population health benefits to be accomplished. Phase 2. Developing implementation plans for the priority guideline recommendations.These should systematically consider skills training and accreditation;social influences including opinion leaders and patient influences;environmental factors; monitoring and feedback; and incentivesfor clinical change. Phase 3. Pilot testing the effectiveness of proposed approaches in producingthe desired clinical changes. If implementation requires systemchanges and evaluation at an organizational level, the use ofalternative research designs to the randomized controlled trialcould be considered. The purpose evaluation would be to enablerefinement of the implementation plans before widespread dissemination.     

Explaining variations in the frequency of night visits in general practice

BACKGROUND AND OBJECTIVE: The study identifies factors which explain variations in thefrequency of night visits made by general practitioners, andis based on a cross-section regression analysis of practicesin Lincolnshire in 1993. METHOD: The independent variables comprise 22 general practice characteristics,related to health and socio-demographic structure of practicelists, practice management and organization, location and socialdeprivation. RESULTS AND CONCLUSIONS: A final model containing 6 of the 22 variables originally enteredsucceeds in explaining 72 per cent of the variation in the frequencyof night visits per GP per quarter-year. These variables areaverage list size per GP, frequency of home visits, maternityclaims, list inflation owing to the influx of temporary residents,the number of proximate practices and unemployment. Keywords. Frequency, general practice, night visits, variables, variations.     

Estrategias para reclutar mujeres inmigrantes para participar en una investigación cualitativa

ObjectiveThe present article aims to describe the process of selecting and recruiting women from distinct sociocultural backgrounds who participated in a qualitative research project and to outline the difficulties encountered according to the women's origin.MethodsResearch was carried out in Barcelona from 2007 to 2008 to identify how culture influences participation in a breast cancer early detection program.ResultsThe study population consisted of native women and immigrant women from developing countries aged 40 to 69 years old resident in Barcelona. Participants were recruited through multiple strategies: key informants, cultural mediators, healthcare professionals, associations, religious institutions, the media, posters, adult education and language schools, and the population census.ConclusionsThe recruitment process cannot be confined to a single source and associations, religion institutions and cultural mediators are the most effective resources.     

Improving outpatient care of depression by implementing practice guidelines: a controlled clinical trial

Objective. Depressive disorders are of great medical and political significance.Although evidence-based guidelines have been published and educationalinitiatives have been launched to implement them, they are rarelyactually used. The aim of the study was to implement clinicalpractice guidelines for outpatient care of depression usinga practice-oriented and interdisciplinary approach. Design. Controlled clinical trial with a naturalistic design (data collectionwithin routine practice) designed as a prospective pre-poststudy. Setting. Outpatient care. Participants. 29 general practitioners (intervention: 18; control: 11) and15 psychiatrists (intervention: 11; control: 4). Overall, thetreatment of 698 patients (two samples: pre: 361; post: 337)was documented. Intervention(s). Multifaceted intervention combining benchmarking, continuousmedical education and interdisciplinary quality circles forthe diagnosis and treatment of depressive disorders. Main outcome measures. Mixed-effects regression models for cluster-adjusted analysisof patients' symptom reduction. Results. Although physicians in the intervention group improved theirclinical effectiveness (proportion of patients with response/remission)to a greater extent than physicians in the control group (intervention:48.6% to 66.9%; control: 54.9% to 61.5%), cluster-adjusted analysisfailed to prove a statistically significant effect of the interventionon the treatment outcome. Conclusions. Although no statistically significant improvements were foundregarding the outcomes, the action programme provides importantwork, materials and results for an integrated treatment modelfor depression.     

How can we get access to the experiences of people with dementia? Suggestions and reflections

This paper suggests and discusses a methodological approach that aims to facilitate the inclusion of people with dementia in research where the ambition is to better understand their experiences. People with dementia have commonly not been included as informants in research as their cognitive deficits have been regarded as a hindrance. Moreover, in the qualitative research tradition, most inquiries rely on data obtained from interviews, thereby requiring communication and verbal skills, which are skills that are affected early in the cause of dementia. Consequently, the considerably under-researched area of how dementia is experienced and managed from the perspective of those afflicted has long been put aside. This paper suggests that a combination of qualitative observations and adapted interviews may make it possible for people with dementia to participate as research informants. Issues concerned with creating a relationship with informants with dementia and helping them to elicit their experiences are elaborated and discussed. Some suggestions are made concerning how the context can be used for this intent, and how the observations and interviews can be adapted to the informants with dementia.     

Doing randomized controlled trials in a developing country: some practical realities

BACKGROUND: Formal randomized controlled trial results are often reported.The difficulties of doing such trials are not. Developing countriesrepresent a new field in which trials can be undertaken. Inthis context even less is known about the practicalities involved. METHOD AND RESULTS: A randomized, double-blind, parallel study took significantlylonger than expected to complete and subject recruitment andparticipation fell short of expectations. Different recruitmentstrategies were used and these performed differently in termsof enrolling trialists. Subjects most frequently left the trialin its early stages. CONCLUSIONS: Possible explanations for these findings include the demographyof the country, cultural factors, and the existence of an establisheddoctor-patient relationship. Keywords. Developing countries, drug treatment hypertension, randomized controlled trials, United Arab Emirates.     

Multidisciplinary team,working with elderly persons living in the community: a systematic literature review

This paper suggests and discusses a methodological approach that aims to facilitate the inclusion of people with dementia in research where the ambition is to better understand their experiences. People with dementia have commonly not been included as informants in research as their cognitive deficits have been regarded as a hindrance. Moreover, in the qualitative research tradition, most inquiries rely on data obtained from interviews, thereby requiring communication and verbal skills, which are skills that are affected early in the cause of dementia. Consequently, the considerably under-researched area of how dementia is experienced and managed from the perspective of those afflicted has long been put aside. This paper suggests that a combination of qualitative observations and adapted interviews may make it possible for people with dementia to participate as research informants. Issues concerned with creating a relationship with informants with dementia and helping them to elicit their experiences are elaborated and discussed. Some suggestions are made concerning how the context can be used for this intent, and how the observations and interviews can be adapted to the informants with dementia.