MISP Implementation
in Kathmandu and
Sindhupalchok, Nepal
Training: Focus Group Discussion (FGD) September 10-12, 2015
Research. Rethink. Resolve.
Samira Sami, MPH DrPH Candidate
Johns Hopkins University
Anna Myers, MPH Research Manager
Women’s Refugee Commission
Agenda
• Day 1: Training
– Introductions
– Staff roles and responsibilities – Overview of the MISP
– Overview of the evaluation methodology – Ethical issues and safety protocols
Agenda (2)
• Day 2: Training
– Introduction to FGD Tools – Practice, practice, practice
• Day 3: Pilot
Introductions
• What is your name?
• Where are you from?
• What are your favorite activities to do?
• What is your research experience?
– Experience in qualitative research
Site 1: Kathmandu
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
Site 2: Sindhupalchok
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
Roles
Facilitator
Notetakers
Interpreter
Responsibilities
Timeliness
Respect
Be prepared
Team player
Ask questions!
Timeline of Activities
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
6 7 8 9 10
Training 11Training 12Pilot
13 14 Data Collection Day #1 15 Data Collection Day #2 16 Data Collection Day #3 17 Data Collection Day #4 18 Data Collection Day #5 19 Debrief Day 20 21 Debrief with stakeholders
Communication Protocol
Security Issues
Administration
Hours and lateness
Planning FGD Schedule and
Participant Recruitment
List of health workers
How to recruit participants and informed consent
Selecting the right environment/setting
QUESTIONS?
Reproductive Health in Crisis
Settings
• WHY do we need to pay attention to RH in a crisis?
• 60% of preventable maternal deaths & 53% of child
deaths occur during crisis
• 4% of population pregnant at any time:
– 15% of pregnant women will need emergency obstetric care
– 9-15% of newborns will need live-saving emergency care
Settings (2)
• How does crisis worsen reproductive health?
– Destruction of health facilities
– Lack of trained staff
– Health facilities overwhelmed
– Breakdown of social structures, families
– Lack of supplies
– No access (displacement, security, cultural restrictions,
knowledge/attitudes towards HC, economics)
What is the Minimum Initial
Service Package (MISP) for
Reproductive Health?
• Minimum:
– Ensure basic, limited reproductive health services
• Initial:
– For use in emergencies, without site-specific needs
assessment
• Service:
– Health care for the population
• Package:
Objective 1: Coordinating
implementation of MISP
priority RH services
Objective 2: Preventing and managing the
consequences of sexual violence
•
Putting in place measures to protect
affected populations from sexual
violence
•
Making clinical care available for
survivors of rape
•
Ensuring the community is aware of
Objective 3: Reducing the spread of HIV
•
Ensuring safe and rational blood
transfusions
•
Enforcing respect for standard
precautions
•
Guaranteeing the availability of
Objective 4: Preventing maternal and newborn death
and disability
•
Ensuring availability and
accessibility of EmOC and newborn
care services at health facilities
and referral hospitals
Objective 5: Planning for
Comprehensive RH Services
•
Collecting existing background data
•
Identifying suitable sites for
future RH service delivery
•
Assessing staff capacity
Additional MISP Priorities
•
Family Planning
•
Sexually Transmitted Infections
•
Prevention of Mother-to-Child
QUESTIONS?
Evaluation Methodology
•
Case study design
–
Kathmandu
–
Sindhupalchok
•
Purposive sampling
•
Population
–
Program staff
–
Health workers
–
Community
•
Methods:
–
Key informant interviews
–
Health facility assessments
–
Focus group discussions
Method Sampling plan Data collection strategy Key informant interviews Program managers and staff • Semi-structured interviews Health facility
assessments 25 health facilities • Structured questionnaire
Focus group
Evaluation of the Implementation of the MISP for RH
among Crisis-Affected Persons in Kathmandu and
Sindhupalchok, Nepal
• Purpose of FGDs
– To qualitatively assess the extent that the MISP has been implemented in Kathmandu and Sindhupalchok since the earthquake
• FGD Objectives
1. To assess the extent that RH services are available and accessible 2. To explore how resources (human and material) relevant to the MISP
were allocated, mobilized, and delivered by agencies in the humanitarian response
3. To explore awareness about and use of RH services by the crisis-affected population
Focus Group Discussions
• Purpose: To understand the knowledge, attitudes, and access of RH
services among the crisis-affected population
• Group composition: no more than 10 participants per group
Age-Gender Group
Site 1 – Kathmandu Site 2 – Sindhupalchowk TOTAL No. of FGDs
near health facilities
No. of FGDs far from health facilities
No. of FGDs near health facilities
No. of FGDs far from health facilities
No. of FGDs across all sites
Girls aged 15-24 years 2 2 2 2 8
Boys aged 15-24 years 2 2 2 2 8
Women aged 25-49 years
2 2 2 2 8
Men aged 25-49 years 2 2 2 2 8
Evaluation Team
Women’s Refugee Commission
Boston University School of Public Health
Johns Hopkins Bloomberg School of Public Health
RIDA research staff
Evaluation Partners
Department of Health (DOH) Nepal
United Nations Population Fund (UNFPA) Nepal
FPAN - SPRINT (Sexual and Reproductive Health Programme in
Crisis and Post-Crisis Situations)
Reproductive Health Sub-Cluster in Nepal
Evaluation Outcomes
• Share findings with evaluation partners to inform the
development of program and policy recommendations
• Improve reproductive health services for people affected by
the earthquake in Nepal
• Disseminate final report for local and international learning
• Inform future emergencies by ensuring quality RH services
QUESTIONS?
Principles of Ethical Research
• Respect integrity & minimize harm
• Informed consent
• Confidentiality
• Privacy
• Secure handling of data
• Sharing results with relevant stakeholders
Elements of Consent
•
* If non-literate, read slowly in appropriate language and
ask for questions
•
Introduction
•
Purpose of Study
•
Procedures
•
Risks & benefits
•
Questions or Concerns
•
Confidentiality
Practice: Informed Consent
• Read out loud
• Identify consent elements:
– Purpose of Study
– Procedures
– Risks and benefits
– Questions or concerns
– Confidentiality
Eligible FGD Participants
•
18 and older → regular consent
•
15 to 17 years: must meet one of these
–
Ever Married
–
Pregnant
Violence
• See Handout
•
Qualitative:
•
Attempts to
explain
•
Complex, changing
(
‘fluid’)
•
Describes
meanings:
•
Perceptions,
knowledge, beliefs,
behaviors
•
Describe variation
•
Behaviors
explained in
context of what is
happening around
them
•
Quantitative:
•
Attempts to
measure
•
Often can
quantify an event
but NOT explain
why it occurred
•
Standardized so
that larger
generalizations
can be made
What happens in a
house, how is a
“home” defined, what
influences what
people do in their
What is qualitative research?
• Qualitative research is
flexible
.
•
Non-leading
questions and statements are used.
• Information is
probed
as much as possible.
•
Participants
are treated
as the expert
.
•
The participants lead the conversation
while staying
on topic.
•
How
and
why
things happen are of most interest.
• The
words
people use are analyzed.
we are trying to
understand perceptions
What is a focus group discussion?
• A
group
interview that emphasizes
communication among group members in
order to generate information about a
Why Do Focus Groups?
• To
collect information
about knowledge, behaviors, what
people think, how they think and why they think that way
• To discover
variety
within a homogenous population
• To assess areas of
agreement
and
disagreement
between
groups
• To develop a
consensus
view on a product
• To
empower
participants, to hear their voices
•
Facilitator - conducts the group interview
– Must be able to ask and clarify a question
– Hear the response
– Determine if further clarity is needed regarding the responses
•
Notetaker- records what is being said or expressed
– Responsible for ensuring detailed documentation of the FG
– Back-up to recording device
– Captures quotes and who is speaking
– Retain specific terms or phrases in local language
– Record body language and nonverbal signals of participants
– Remind facilitator of issues overlooked during the discussion
Research. Rethink. Resolve.
facilitators?
• Language and communication skills.
• Familiarity with the content and structure of the activity.
• Familiarity and comfort level with discussing reproductive health topics. • Ability to respect the dignity and confidentiality of participants.
• Previous experience conducting focus groups or other qualitative activities. • Ability to multi-task and be flexible with adjusting questions as needed.
Steps for Conducting a FGD
1.
Prepare materials for FGD
2.
Greet participants
3.
Introduce yourself and the team
– Explain purpose of interview
– Describe link to local partners
4.
Conduct informed consent
– Cannot promise other participants of the FGD will not share
– Encourage FGD participants not to reveal identities
– Avoid using participant’s names during the FGD
– If participants refuse to participate, thank them for their time and they can be excused from the group at any time
5.
Give a few brief group rules
– One speaker at a time
– No side conversations
(2)
6. Move to first specific topic
– “Thank you. Let’s start with our first topic.”
– “One thing I’ve heard several people mention is _____. What else
can you say about that?” or “I’m surprised no one has mentioned ____. Does it matter or not?”
– Track connection between conversation and guide.
7. When closing, provide a summary of the
discussion
–
Summarize key points of discussion with groups to
make sure important points have been captured.
–
Ask if there’s anything else to add
–
Don’t give out cookies/drinks until the end.
–
Share the locations of existing services for
participants to access additional information and
services.
What is probing?
• A way to encourage participants to say more and explain why or how to get as much information as possible.
• Types of probes are:
– Why or what questions: “What do you mean when you say…”
– Silent probe: Staying silent but supporting the participant to continue talking.
– Echo probe: Repeating the last point raised by the participant. “I see. You said that people might talk to friends if they have a problem. Tell me more about that. What happens then?” Be careful not to repeat something different than what was said,
as this would be leading.
– “Uh huh” probe : “oh,” “Uh-huh,” “I see”.
• Other examples:
– “Can you explain further?”
– “Can you give me an example?” – “Can you say more?”
– “I am not sure I understand x. Would you explain that to me?” – “How do you feel about…”
What are good ways to probe?
• “What do you mean when you say…” • “Can you explain further?”
• “Can you give me an example?” • “Can you say more?”
• “I am not sure I understand x. Would you explain that to me?” • “How do you feel about…”
• “Is there anything else?”
What is a leading question?
• Leading questions are said in a way that suggests a particular answer
or implies that one answer is expected or more correct.
• If leading questions are used, participants might be more likely to
agree with what we ask or think we are looking for a particular answer. • Participants are less likely to say what they really think.
What is a leading question?
Leading questions:
• “What fears do you have when your baby’s diarrhea does not stop?”
• “Why didn’t you take your baby to the health center for treatment?”
• “How good was the treatment at the health center?”
Non-leading questions:
• “What do you think about when your baby’s diarrhea does not stop?”
• “What do you do when her/his diarrhea does not stop?” • “How do you feel about the treatment your baby got at the
health center?”
Research. Rethink. Resolve.
How should a facilitator facilitate?
• Listen to participants and concentrate on what they are saying. • Ask questions one at a time.
• Show interest and understanding.
• Encourage participants to feel comfortable sharing as much information as possible.
• Remind participants to share information about the general situation and not their personal situation.
• Listen for causes and characteristics of an issue. • Be silent when silence is needed.
What are things the facilitator should avoid?
• Nodding your head, smiling, frowning or using other body movement that can show a biased or judgmental attitude.
• Giving answers to the questions and/or agreeing verbally with the answers.
• Being impatient.
• Judging the answers (e.g., saying, “It is good”).
• Cutting off the participants’ answers in the middle of their sentences. • Letting two or more participants talk at the same time.
• Sharing your personal opinions. • Arguing with participants.
• Losing control of the discussion to participants that dominate the conversation.
• Skipping any participant during the discussions.
need to manage?
Research. Rethink. Resolve.
Challenge Suggested Response
Talkative Thank them for their contribution Invite others to comment
Encourage them to make one point at a time Asking lots of questions Write question on flip chart and return to them
Prioritize which questions to focus on Tired Take a break
Anger Acknowledge emotion or sensitivity
Steer towards sensitive issue rather than person Shy Encourage to contribute by calling pseudo name
Ask if agrees/disagrees with what has been shared Personalities Use pleasant and patient tone
Add humor, where appropriate
How can different participants be managed?
• Participants that are “the expert,” too talkative, rambling or politically inclined:
o Use verbal and non-verbal communication, such as body motion and eye contact.
o Repeat the topic question so that the participant understands the topic.
• Participants that are scared, shy or confused:
o Give more attention and encouragement through using eye contact and by being patient.
Research. Rethink. Resolve.
notetakers?
• Excellent listening skills with the ability to listen while writing notes in an format without slowing the tempo of the discussion unnecessarily.
• Able to write verbal and non-verbal responses • Ability to listen without making comments
• Ability to respect the dignity and confidentiality of respondents.
• Ability to multi-task and recognize when the facilitator has altered the sequence of the questions, which requires a strong familiarity with the study tool.
• Date must be recorded in a format that is readable, understandable, and
complete
• Ability to concentrate and write notes for a period of up to 2 hours in length.
Expectations of the Notetakers
Research. Rethink. Resolve.
• Assign speaker identifiers and note who says what • Retain specific terms or phrases in local language
How to Record a FGD
1. Prepare the audio recorder and environment for the discussions 2. Document the ‘FGD Details’ on the guide.
3. Obtain informed consent before recording the discussion 4. Record participant identifiers
5. Make sure you clearly indicate in your notes how you are recording nonverbal behavior and your own comments 6. Record additional questions/probes by the facilitator 7. Indicate symbols for facilitator
– Place marks in margins that so that it is easily seen when you are scanning the notes for completeness
– * could signify that a sentence or answer needed more clarity
8. Speak up if pace of FGD is too fast for recording
9. Coordinate with your team before closing the discussion
Recording Nonverbal Behavior
• Guidelines:
– First, does it add to the interpretation of the FGD?
– If yes,
• Write a short description of the behavior
Example: Nonverbal Behavior
• “You know, we have hired assistants to work on
projects at [Organization redacted] and some of our
projects that I'm directly involved in-- some are
involved as staff, but yeah. So, um, because,
Tracking Participant Responses
• In your notebook, draw how participants are seated, and assign a number to each person to track who says what.
• If participants will move around, simply assign a number that you can remember for each person.
Research. Rethink. Resolve.
Facilit
Real life example
Question: What would you say are the barriers or challenges for women to begin using contraceptives?
[2]: I know how to use methods (just pills), but there are challenges, such as lack of awareness among both women and men. Husbands prevent wives from using the pill. If I want to use it, I use it in a secret way.
[4]: Using the pill will prevent women from having many children. Some people produce ten children and some lose three. They remain with seven children. If they take the pill, they may only have a few children, and if they die, that will be bad luck. If we produce more than 12
children, if six die, we still remain with six.
[7]: Some forget to take the pill because of too much work. By the end of the day, the mind is too tired and we cannot remember to take the pill.
Example continued
[1]: Fear of our husbands is another issue.
[3]: Small girls fear their parents and families. There is a lack of awareness and incorrect information. There are also no CBD [community-based distribution] agents in their area. The husband also opposes.
[Facilitator]: Is there anything else? Can you think of other reasons?
[5]: We need more information on how to be aware of the rest of the methods. For condoms, we do not know how to use it. Even men cannot accept. We can only use injections or pills.
Many nod their heads in agreement.
Research. Rethink. Resolve.
What is a debriefing session?
• Immediately following an activity, the
facilitator and
notetaker
should come together
to discuss the
session
and address areas of improvement.
1. Facilitator and notetaker review responses by
having the notetaker verbally review each response
that she or he has written for each question.
2. Facilitator can add any missed information.
3. Facilitator and notetaker discuss the responses for
any noteworthy thoughts.
Debriefing at the End of the Day
• Make sure you understand the definition of terms or
phrases used in the local language:
– Get agreement from your team
– Keep a record of word in original language
• Debriefing is the start of analysis: you look at the data
and make sense of it
Research. Rethink. Resolve.
Expectations of the Transcriber
• Transcribe the FGD word for word (include every
word as spoken), include non-verbal observations
• Include facilitator’s questions and comments
• Include pauses, interruptions, laughter, silences, and
other unspoken dynamics in the transcript (use
notes)
What happens during transcription?
• Once the data collection is finished, the research team will share
and discuss their notes.
• One note taker will merge the two sets of notes and translate
and type one transcript.
• In the process:
•
Compare the transcript to the handwritten notes
to match
speakers and add any missing information.
•
Add any non-verbal observations
that were noted by hand
so that the transcripts ultimately contain all of the information.
•
Refrain from adding any identifying information (such as
names of people)
Transcription Keys
Key
•[Text] Indicates speech by the person who was not the primary speaker at the moment, i.e. “yeah”, “Mmhmm”, or other short non-substantive affirmations, probes or interjections.
•[Text] Description of body language or other environmental context.
•… Indicates a pause. Length of pause indicated by number of dots: … vs. … …
• Indicates that the sentence was cut short by an interjection by the other speaker.
•— Indicates a quick transition in ideas, consistent with its typical grammatical use.
•? Indicates that the sentence was spoken with a questioning tone, consistent with its typical grammatical use.
•, Indicates a natural transition pause while communicating a continuous thought, consistent with its typical grammatical use.
•. Indicates the natural end of one thought, followed by the beginning of a new one or speech by the other speaker, consistent with its typical grammatical use.
• “____” Indicates that the speaker is imitating the speech of a third party who is not present, or is in fact quoting a third party who is not present, consistent with its typical grammatical use.
Important information about transcriptions:
• Transcriptions have to be written word for
word.
• Summaries, missing pauses, shortening
rambling statements, rephrasing, etc., cannot
be done.
• Everything that is said, along with actions and
gestures of importance,
must
be included in
your transcript.
Guiding principles
• Speak slowly and clearly
• Repeat when needed
• Be courteous and attentive
– Do not yawn
– Take a break if they want
Guiding principles (2)
• Be neutral and accepting
– Do not use judgmental language
• Listen carefully to the answers
Guiding principles (3)
• Establish and maintain boundaries
– Let the respondent know you are listening but also
focused on completing the interview
– Listen
– Maintain neutral role
• Pause if needed
• Stay focused on the respondent
Guiding principles (4)
• Treat the respondent with respect
• Do not act as a counselor
– We are not social workers
– If respondent is concerned, provide a referral to
services
Practicing with examples…
• Facilitators
o
Practice obtaining informed consent.
o
Practice facilitating a short discussion or activity with
participants.
o
Practice closing the discussion or group activity.
• Notetakers
o
Practice taking notes and documenting observations.
Practicing with examples…
• Participants
o Play different types of participants, including those with different impairments, the talkative and quiet.
• Debrief
o Notetaker reviews group proceedings.
o Participants to point out any missed information and offer
suggestions to facilitators on ensuring inclusion and maximum participation.
• Change roles
Does the interviewer introduce her/himself?
Does the interviewer ask for informed consent?
Does the interviewer try to make the
interviewee comfortable? (i.e., good eye contact, nodding of head, smiling,
encouraging behaviors)
Does the interviewer tell the interviewee what to expect and how long the interview might last?
Practice Discussion
• What went well?
• What difficulties did you encounter
womens
refugee
commission.org
