METHODOLOGICAL FRAMEWORK
Introduction
This chapter outlines the methodological approach employed for this research, which sought to understand the social conditions of a case study comprising vulnerable young women as they influence the group’s treatment for MDR-TB via a public health facility in a metropolitan area. The study concerns itself with understanding participants’ interpretations of a phenomenon at a particular time and within a specific context (Snape and Spencer 2003; Merriam 2002). It was approached with the aim of achieving rich and nuanced descriptions of the subjective and context-determined motivations advanced by research participants (Snape and Spencer 2003) to explain vulnerable young women’s sub-optimal adherence to MDR-TB treatment, and the situated and complex factors occurring over time that impact their abilities to take medication as prescribed until completion.
Qualitative research methodology approaches were applied in conceptualising the research design and implementing the data collection and analysis processes employed. Decisions about methodology were influenced by the objective of the research to comprehensively explain how communication can support improvements in adherence to MDR-TB treatment among a specified vulnerable population. A flexible and iterative research style was adopted, and a multi-pronged recruitment strategy and various data collection methods employed. This study included purposively selected participants and applied a naturalistic, inductive, interpretive approach to collect data (Snape and Spencer 2003). Discussions of the data analysis process in Chapter Seven and the presentation and analysis of findings in Chapters Eight and Nine are rooted in my collection, analysis and interpretation of personal accounts of human participants obtained via focus group discussions and key informant interviews, as well as some observation and reference to the reflexive journal kept during data gathering (Snape and Spencer 2003; Merriam 2002).
This study’s methodological and data analysis procedures are presented in separate chapters, to allow for ample attention to laying firm enough foundations to shore up the research findings presented later in this thesis. While this chapter presents the methodological approach, Chapter Seven presents comprehensive discussions of the application of Braun and Clarke’s (2006) six-step approach to thematically analyse data for this study. Discussions in both chapters are equally essential for linking the
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research questions and objectives to findings of this study which are presented in later chapters. They provide directions that make clear how this research was conducted and how it arrived at the conclusions advanced in Chapters Eight and Nine. To achieve this, unabridged explanations are offered.
Research paradigm – qualitative research methodology
Strategies, methods and approaches applied in this study are informed by an ontological position that qualitative research aims to produce culturally and historically specific knowledge (Jankowski and Wester 1991; Jensen 1991) that can only be understood through appreciating the socially constructed meanings that study participants make of it (Starman 2013; Snape and Spencer 2003). Qualitative research’s emphasis on examining participants and their contexts of communication as socially specific objects of analysis (Jankwoski 1991; Jensen 1991; Green 1991) influenced the decision to utilise this methodology for this study. The relationships among the research epistemology, theoretical perspectives, methodology and research methods adopted for this study is highlighted in Figure 13.
Qualitative researchers apply theories as research progresses and are not particular about using philosophies to guide the design of research. This is unlike quantitative research studies, which deductively advance hypotheses that must be proved through further research and testing (Merriam 2009). Qualitative research is useful for studies which aim to discover novel or unanticipated findings (Jensen 1991; Freedman et al.
1974). Research in this tradition results in reports in the following forms: ‘(i) descriptions which make little or no reference to theoretical perspectives; (ii) analytical discussions based on concepts emerging from the study; and (iii) substantive accounts intended to contribute to general theory’ (Jankowski and Wester 1991:69).
This research is written in line with the tenets of the third category, insofar as it adopts a communication model-building approach.
Describing the epistemological positioning of research is important for, among others, supplementing researchers’ perceptions when defining the focus and aims or studies, when collating and designing the research approach, and in articulating characteristics of participants, or groups of participants sought to contribute to specific research (van Nierkerk 2005). Van Nierkerk’s (2005) argument that all models of clinical intervention are couched in epistemology, and that none exists in a vacuum influenced this study’s involvement of human participants to unlock knowledge about a case study of vulnerable women resident in low socioeconomic urban communities. Hoffman
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(1981) explains that epistemology reflects rules that people use to make sense of their world. Aurswald (1985:1) expands this by explaining that ‘epistemology is a set of imminent rules used in thought by large groups of people to define reality and is the study or theory of the nature and grounds of knowledge’. This study’s epistemological position derives from Munro et al.’s (2007b) claim that there exist ‘lay theories’ about TB treatment adherence within those taking treatment, and that only by engaging patients in their environments and in line with an appropriate conceptual framework, can we unlock and uncover these theories and build them into practicable models.
Figure 13: Relationship between epistemology, theoretical perspectives, methodology and research methods
Epistemology Theoretical perspectives
Methodology Methods
Social constructionism Interpretivism Quasi-ethnography Observation Interview Focus group Case study
Source: Adapted from Gray 2004; Crotty 1998
Research that aims to close observed gaps in available theory is termed ‘inductive’ and derived from an approach introduced by Isaac Newton and Francis Bacon in the 17th century (Snape and Spencer 2003). They suggested that it was possible to secure knowledge about the world through direct observation, as opposed to through testing abstract theories (Snape and Spencer 2003). Inductive research such as this one denotes scholars designing and developing research studies and undertaking data collection with the primary objective of amassing information that results in the development of ideas, premises or theories ‘from observations and intuitive understanding gleaned from being in the field’ (Merriam 2002:5).
Assertions that qualitative researchers often implement academic inquiry to probe specific fields or issues because of observed lack of relevant theory to explain a phenomenon or develop responses to it partly influenced the decision to undertake this study as a qualitative investigation (Merriam 2002). The idea also informed this study’s aspiration to contribute an inductively derived health communication model
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to hopefully improve adherence to long-term treatment among vulnerable populations in South Africa (Merriam 2002). There are arguments that ‘Because theories are uncovered through the researcher listening and becoming immersed in the research experience and findings … theory developed in this way provides more sophisticated explanations than those derived from other studies’ (Chong and Yeo 2015:258). This view impacted the study’s design and implementation, including choice of research participants and their recruitment, type of data collected and location of data collection, as well as the analysis of data and presentation of findings.
Epistemology of research: Social constructionism
Social constructionism was selected because studies within its tenets adopt a social, rather than individual focus (Young and Colin 2004, in Andrews 2012). Researchers argue that information and understanding is ultimately derived from a ‘knowledge community’ of people who agree on a truth, and dispute narratives that foreground the validity of individual accounts of reality (van Nierkerk 2005). Indeed, proponents of this epistemology postulate that single explanations of reality do not carry equal weight, and that some instead result in complications (Dickerson and Zimmerman 1996, in van Nierkerk 2005). Social constructionism was deemed compatible with the approach to this research due in part to its ability to compel me to contemplate and remain aware of my social class, socioeconomic status, nationality/culture, gender and age, among other factors, as they influenced my perspective during research (van Nierkerk 2005).
As the name suggests, social constructionists consider knowledge as created or constructed, rather than discovered (Andrews 2012), and are concerned with understanding phenomenon from the perspective of the researched (van Nierkerk 2005). They foreground contributions of social and cultural contexts to how individuals perceive, make sense of, and articulate the world (van Nierkerk 2005). In this school of thought, society is viewed as existing as both a subjective and an objective reality. Proponents strive to understand experiences and lived realities of individuals and groups studied from their own standpoints (Andrews 2012) but with the understanding that there are no independent facts that can be known, because facts, together with ideas and assumptions, are social constructs, or inventions of socially promoted discourse (van Nierkerk 2005). Because meaning is believed to be shared between individuals and social groups in specific contexts, it assumes a taken- for-granted reality (Andrews 2012), which allows for research findings to be generalised to groups situated in defined social and cultural contexts. It was
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considered necessary to contemplate the potential of these issues to affect interactions with marginalised women of predominantly Zulu ethnicity who contributed to this study.
The epistemological positioning impacted how data was collected and analysed, as well as the approach adopted for data presentation and discussion. Analysis of findings presented in this thesis is guided by appreciation that social constructionism is principally concerned with how research participants define or elucidate their experiences, rather than dwelling on whether their accounts precisely replicate
‘reality’ (van Nierkerk 2005). Social constructionists’ acknowledgement of the equal participation of research participants and researchers as ‘co-creators of shared reality’
during research (van Nierkerk 2005) is important to mention, as it influenced how data collection was handled, what was deemed important to include during engagement with the raw datasets, and decisions taken in analysing data as outlined in Chapter Seven.
Research design: Single descriptive case study
One of the main aims of this research – to understand the various and context-specific reasons why vulnerable young women receiving treatment for MDR-TB may find it difficult to take all treatment until completion – could have been satisfied by employing one of eight types of qualitative research approaches. These include (i) grounded theory, (ii) phenomenology, (iii) narrative analysis, (iv) ethnography, (v) case study or (vi) basic interpretive study, (vii) critical, and (viii) postmodern/post-structural (Merriam 2009). Denzin and Lincoln (2000) also identify eight qualitative research strategies: (i) case study, (ii) ethnography, (iii) phenomenology, (iv) grounded theory, (v) biographical, (vi) historical, (vii) participatory, and (viii) clinical.
From these approaches, this study employed a single interpretive quasi-ethnographic case study situated in the social constructionism paradigm (Murtagh 2007; Merriam 2002; Yin 1984) as the research design (Starman 2013; Verschuren 2011 in Simmons 2009). Social constructionism advances this study’s aim to articulate participants’
concerns and experiences in-context and, through my interpretation of data gathered for this study to say, ‘what it’s like’ (Larkin et al. 2006:104) for young poor Black isiZulu-speaking women to take treatment for MDR-TB in marginalised modern urban communities where, some might say paradoxically, cultural beliefs and traditions remain central to health-seeking behaviour as discussed in Chapter Eight. Data gathering was approached carefully to privilege what participants wanted to share about the phenomenon under investigation and to obtain detailed accounts. This
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influenced the data collection tools used and the data collection approach, which is explained in detail later in this chapter.
In the initial stages of data collection, core theoretical concepts were identified, and weak connections made between central concepts and data (Simmons 2014). The first stage of research was open, and followed by verification, summarising and analysis of findings in an iterative process (Simmons 2014). Analysis and data collection informed each other in a cyclic fashion, with early analysis pointing to specific strands of inquiry to follow and highlighting what to look for next in the data collection process (Research Methods Knowledge Base no date), was integral to the research process of this study, into an area where little was known about how health promotion can contribute to improving treatment adherence and outcomes in the KwaZulu-Natal MDR-TB programme.
This study does not consider case study a type of qualitative research as advocated by authors such as Simmons (2009); it instead defines case study as a ‘general term for the exploration of an individual, group or phenomenon (Sturman 1997:61, in Starman 2013:31). I am more sympathetic to Merriam’s (2009:2) definition of qualitative case study research as ‘an intensive, holistic description and analysis of a bounded phenomenon such as a programme, an institution, a person, a process or a social unit’.
A small group of culture-sharing young women aged 18 to 34 years resident in marginalised socioeconomic contexts and receiving treatment for primary MDR-TB at King Dinuzulu Hospital, eThekwini Metro, was this study’s distinctive case of investigation. In framing this investigation as such, I considered the delineated sample and research objectives which together converge with Goetz and LeCompte’s (1984:2) position that a case study is ethnographic if it presents a sociocultural interpretation of data that unpacks the ‘shared beliefs, practices, artefacts, folk knowledge and behaviour of some group of people’ in relation to a phenomenon under investigation. The approach employed is defined as quasi-ethnography due to the relatively short time span of data collection, when compared to true ethnographic investigations, and the element that while I made frequent visits to eThekwini Metro for data collection, I did not aim to fully immerse myself in communities where MDR- TB patients live for extended periods (Murtagh 2007).
The single descriptive quasi-ethnographic case study approach adopted complements the qualitative research methodology utilised. The approach was invaluable for supporting probing of the developmental and practice-oriented factors surrounding MDR-TB communication and health literacy initiatives in eThekwini Metro, and long-
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term treatment adherence challenges among a heterogenous group of people, especially as it focused on a unique case and subject in-context (Starman 2013;
Simmons 2009; Yin 1984). It also informed the research design and its implementation, to support appreciation of the ‘particularity, the uniqueness of a single case’ (Simmons 2009:3); in this instance vulnerable young women with primary MDR-TB in the continuation phase of treatment as outpatients.
Selecting participants and determining the study sample size Qualitative research aims to learn about phenomena of interest that usually include people as research participants by understanding everyday life and topics of investigation from the perspectives of the researched (Palton 1991; Bryman 1988:61).
The research methodology was employed towards achieving comprehensive understanding of subjective motivations driving MDR-TB female patients’, household contacts’, healthcare workers’ and KwaZulu-Natal Provincial Department of Health personnel’s perspectives and conduct in-context. It was applied to support understanding complex human behaviour occurring over time, to emerge with detailed explanations about the phenomenon of low treatment adherence among MDR-TB patients and the role of communication in enhancing adherence rates.
It was important for the research to understand, from the perspective of the researched, how health literacy approaches and content could contribute to improvements in MDR-TB treatment completion and cure rates in the metro. The study thus primarily sought contributions from young women aged 18 to 34 years being treated for MDR-TB at King Dinuzulu Hospital who had no history of having been treated for TB in the past and could, therefore, confidently be assumed to have acquired, rather than developed, MDR-TB infection. Although the recruitment strategy did not specify that participants should be from marginalised communities, the epidemiology of MDR-TB in eThekwini Metro established in Chapter Two and the fact that the recruitment site was a public hospital, conspired to ensure that many women with MDR-TB who participated in the study reported residing in townships such as Avoca, KwaMashu and Inanda (North Service Area) and Umlazi (South Service Area), among others. A World Bank report defines townships and informal settlements as large, underdeveloped communities where 38 per cent working-age people reside (Mahajan 2014). The same report estimated that approximately 50 per cent of South Africa’s urban population lives in a township or informal settlement, areas which house 38 per cent of working-age citizens and are home to nearly 60 per cent of the unemployed (Mahajan 2014).
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The DR-TB Unit at King Dinuzulu Hospital was purposively selected as the recruitment site for participants (Guetterman et al. 2015) because it houses the largest specialised DR-TB Unit in KwaZulu-Natal, which also handles all complicated cases in the province. Each month the hospital initiates on average 250 new patients onto MDR-TB treatment and provides services to an estimated 2,500 patients (Maharaj et al. 2016). Additionally, patients receiving treatment at other DR-TB decentralised sites in KwaZulu-Natal are also periodically reviewed at King Dinuzulu Hospital. Based on this, I believed that the sheer number of MDR-TB patients accessing services at King Dinuzulu Hospital positioned this facility as a particularly rich site from which to identify and recruit the total number of young women with primary MDR-TB anticipated to be adequate for this study.
Sampling participants to the study
Clearly articulating steps taken to define and recruit samples for academic research is critical to ensuring the validity and replicability of qualitative studies, and for avoiding the introduction of bias into research findings via poorly selected participants (Benoot et al. 2016; Guetterman et al. 2015). This study utilised a combination or mixed purposeful sampling strategy as proposed by Patton (2002) to identify different categories of participants. He proposes 16 purposeful sampling strategies for primary research, and describes the logic of purposeful sampling techniques as lying
in selecting information-rich cases for study in-depth. Information-rich cases are those from which one can learn a great deal about issues of central importance to the purpose of the inquiry, thus the term purposeful sampling.
Studying information-rich cases yields insights and in-depth understanding rather than empirical generalisations (Patton 2002:230).
Responding to criticism in literature and considering assertions that the ‘how’ of purposive sampling is not always explicated in academic studies, this research considers it imperative to explicate how the sampling criteria and sample size were determined and participants recruited into the study. This is also done in response to scholars’ critiques that ‘researchers who claim to have used a purposeful sampling approach often fail to create a transparent audit trail on the review process’ (Benoot et al. 2016:2). Explanation are thus provided to avoid this documented flaw, by expatiating the step-by-step process of how participants were decided and selected, recruited and reached.
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The sampling strategy employed primarily aimed to recruit vulnerable women on treatment for and in remission of MDR-TB. The ideal sample emerged firstly, organically during development of the study’s conceptual framework and research questions (Palinkas et al. 2015). Secondly, the decision to recruit only young women aged 18 to 34 years being treated for primary MDR-TB at the time of data collection, and at a specific public healthcare facility in an urban setting served to increase the homogeneity of this category of research participants, allowing for the sampling strategy delineated below to be more confidently applied (Benoot et al. 2016; Palinkas et al. 2015; Patton 2002).
Because this investigation sought to comprehend the challenge of sub-optimal adherence to MDR-TB treatment among a group of culture-sharing young women, it was of primary interest to achieve depth of understanding of the phenomenon being investigated (Palinkas et al. 2015; Benoot et al. 2016). This could be accomplished by including other stakeholders as participants, to triangulate data about the varied reasons for women’s difficulties with MDR-TB treatment from multiple perspectives (Palinkas et al. 2015). Sourcing data on from a cross-section of participants in horizontal and vertical connexion to each other, and to women being treated for MDR-TB became necessary (Palinkas et al. 2015).
The inclusion of more respondent strata to contribute to this research naturally flowed from the identification of vulnerable young women as the principal group of interest to this study. Research which samples a cross-section of participants avoids the risk of missing out on the viewpoints and experiences of other groups that are involved in and/or are affected by specific phenomenon under investigation and lends breath of understanding to research (Palinkas et al. 2015). This consideration influenced interest in the contributions of other participant categories, such as health department personnel, nurses, healthcare providers and family members of women with MDR-TB.
KwaZulu-Natal Department of Health personnel were sampled because of their involvement in MDR-TB management policy development and implementation.
Nursing staff and health educators were interviewed for their potential to contribute unique insights about reasons for young women’s sub-optimal adherence to MDR-TB treatment. Finally, household contacts of women being treated for MDR-TB were included. The research sought to identify convergence in collected data, with that inchoate information then analysed and applied to developing the communication