STUDY AIMS AND METHODOLOGY
3.3 STUDY METHODOLOGY
3.3.9 CODING AND ANALYSIS
Malterud (2001) recommends that researchers ‘follow a path that has been trodden by others’ (p. 487). To structure an approach to coding and analysis, guidelines for Thematic Analysis (Braun & Clarke, 2006) were used, which were supplemented with guidelines for Interpretative Phenomenological Analysis or IPA (Smith & Osborn, 2008; Willig, 2008). It was hoped that by supplementing guidelines for Thematic Analysis with recommendations from IPA, themes could be developed that captured meanings attributed by participants to their experiences (Willig, 2013). The latter has been argued to be a useful analytic approach when issues related to ‘sense-making’ are important (Smith & Osborn, 2007, p.520) and when the issues are ‘complex’ or ‘dilemmatic’ (Smith, 2002, p. 132/3 in Brocki & Weardon, 2006, p. 99) or of ‘considerable moment’ to participants (Smith, 2004, p. 49).
IPA is centrally concerned with subjective experience (Eatough & Smith, 2006) specifically the texture of experience (Willig, 2008). Besides often being used to explore topics in health (Brocki & Weardon, 2006) it seemed to be a most appropriate analytic approach for this study because it aims to establish ‘how participants are making sense of their personal and social world, and the main currency for such a study is the meanings particular experiences (…) hold for participants’ (Smith & Osborn, 2008, p. 53) or the meanings that are assigned to
individuals perceive the particular situations they are facing, how they interpret their experiences (Reynolds & Prior, 2003), and their personal accounts of a phenomenon (Smith &
Osborn, 2008).
IPA assumes that participants’ experiences are mediated by the expectations they bring to bear (Willig, 2008). Participants are understood to be self-interpreting (Koch & Harrington, 1998) and meaning-making agents (Eatough & Smith, 2006). It assumes that it is impossible to gain direct access to participants’ worlds and that researcher conceptions are a ‘necessary precondition’ for understanding such experiences (Willig, 2008, p. 69). Therefore the knowledge produced using this approach is reflexive (dependent on the researcher’s standpoint) and not naively realist. The resultant analysis necessarily implicates the researcher’s view of the world. The analysis is held to involve a double interpretation process where the researcher attempts to make sense of the participants trying to make sense of their experiences (Smith, 2004; Smith & Osborn, 2008) and where the researcher is involved in a process of ‘interpretive engagement with the texts and transcripts’ (Smith, 1997, p. 189 in Willig, 2008, p. 57). Analysis is therefore committed to foregrounding participants’ subjective experiences while recognizing that this requires interpretive work from the researcher (Smith
& Osborn, 2007).
The active role of the researcher in developing themes and reporting them is acknowledged (Taylor & Usher, 2001 in Braun & Clarke, 2006, p. 80). The approach may refer to themes that
‘emerge’ from the data, however, this is viewed as a selection process requiring interpretation on behalf of the researcher (Flowers, Duncan & Frankis, 2000). It is understood that the analytic account rests on the joint reflections of participants and the researcher (Brocki & Weardon, 2006). The researcher seeks to understand the account presented by participants whilst simultaneously making use of his or her ‘interpretive resources’ (Smith, 1999, p. 223 in Brocki & Weardon, 2006, p. 96). It is understood that participants’ meanings are not merely available but must be ‘obtained’ through a process of interpretation (Smith &
Osborn, 2008, p. 65). This approach views both the participant and the researcher as participating in the process of sense-making (Smith, 1999).
The researcher should foreground the study participants’ perspective as well as offer an account of what it means for study participants to have these concerns in their context (Larkin, Watts & Clifton, 2006). This can exceed the terms and conceptualizations used by participants (Smith, 2004, in Larkin et al., 2006). The researcher is free to draw on various interpretive possibilities provided that a recognizable core account focussing on participants’
experiences is visible and central (Larkin et al., 2006; Reid, Flowers & Larkin, 2005). The researcher should combine an empathic stance, where the researcher is trying to understand participants’ viewpoints and experiences, with a more tentative questioning or interpretive stance where the researcher tries to gain insight into the nature and meaning of those experiences (Willig, 2008). It is recommended that the empathic reading be done first, followed by a more critical yet speculative reflection (Smith, 2004). This approach does not attempt to bracket previous knowledge to better understand the essence of a phenomenon as advocated by some traditions of phenomenology (Willig, 2008). However, the researcher should foreground the participants’ accounts before making theoretical connections, or drawing on theoretical accounts, or locating experiences in the existing literature (Eatough &
Smith, 2006; Green, Willis, Hughes, Small, Welch, Gibbs & Daly, 2007; Larkin, Watts &
Clifton, 2006). The overall outcome should be renewed insight into the phenomenon as experienced by participants (Larkin, Watts & Clifton, 2006) where the reader’s appreciation of subject matter is clarified and expanded (Elliot, Fischer & Rennie, 1999).
The steps recommended by proponents of Thematic Analysis (Braun & Clarke, 2006) and IPA (Smith & Osborne, 2008; Willig, 2008) were summarized, and a ‘hybrid’ set of steps was developed. There was overlap between them, but these authors appeared to use different terminology for labelling a basic segment of text with Braun & Clarke (2006) referring to
‘codes’ and Smith & Osborn (2008) referring to ‘themes’. The following steps were undertaken:
3.3.9.1 Step 1: Reading and re-reading the interview transcripts
In this preliminary step, the researcher is encouraged to read and re-read the text (Braun &
Clarke, 2006; Willig, 2008). In these initial readings the party being referred to was noted - enrolled participants or persons that volunteered to take part but did not necessarily get enrolled or to community members more generally. In these initial readings the need being
referred to was also noted - HIV needs or sexual/ reproductive needs or more general conditions. These references in the transcripts were not at all surprising because interviewees had been asked questions about these parties and needs during semi-structured interviews.
3.3.9.2 Step 2: Developing first-level codes
In this next step, the researcher is encouraged to code the text by assigning labels to basic segments of the text (Braun & Clarke, 2006) or attributing a word or phrase to segments of text (Green et al., 2007). The text was assigned a code according to the practices being referred to - using verbs or the language of practices, such as ‘providing HIV counselling to participants onsite’, or ‘counselling participants to access HIV care’. It was important to identify actions that were being implemented by site-staff, and other stakeholders, as part of the process of identifying how they make sense of their actions. Codes were ‘active’ and ‘specific’
to help identify practices that may otherwise remain implicit (Charmaz, 2008, p. 98). Codes took the form of meaningful phrases (Miles & Huberman, 1994).
I was previously sensitised to certain practices recommended in ethical guidelines, and found in previous empirical assessments, such as ‘referring for ART’. These constituted deductive codes or ‘top-down’ codes (Quinn-Patton, 2002a). However many practice codes were developed from reading of transcripts, such as ‘seeking permission to share results’ that constituted inductive or ‘bottom up’ codes. Therefore a combination of deductive and inductive coding was used. In assigning these practice codes, text was labelled in a semantic and explicit way, using the surface meanings of the data (Braun & Clarke, 2006) or ‘everyday terms’ (Sandelowski, 2000, p. 338). It was hoped that these codes would be accessible and credible to the persons who provided the information and relevant stakeholders (Quinn Patton, 2002a). Text was also labelled to capture key perceptions, that is, how interviewees were seeing things or how they were understanding things or how they were making sense of their actions. In assigning labels here, efforts were made to stay close to the words used by interviewees to ensure their viewpoint was being foregrounded. Examples of sense-making codes include ones such as ‘seeing as a response to participants’ contributions’ or ‘seeing that participants ‘step up’. Adopting this kind of coding was a deviation from recommendations in IPA that assigning labels at this early stage be conceptual using theoretical terminology at a higher level of abstraction (Smith & Osborn, 2008; Willig, 2008).
3.3.9.3 Step 3: Listing first-level codes
At this stage, the researcher is encouraged to list their emerging codes for each separate interview and examine them closely (Willig, 2008). Problems were identified at this early stage. A review of the codes generated for the first few interviews showed far more ‘action’
(practice) codes than ‘sense-making’ or perception codes. It seemed that the need to document actions or practices articulated by interviewees was interfering with coding text capturing how they were making sense of their experiences. This ‘practice-focus’ was linked to my involvement in the broader project (funded by the Wellcome Trust) that aimed to assess whether stakeholder practices for care (and prevention) corresponded with ethical requirements. That project aim required that practices be articulated and evaluated to see how well they resonated with expectations set out in ethical guidelines. Ethical guidelines appear primarily concerned with stakeholders’ conduct (and less with their perceptions) therefore to implement that funded project properly a clear account of conduct was required.
To ensure a clearer account of how stakeholders were making sense of their actions, initial interviews were re-coded.
3.3.9.4 Step 4: Sorting first-level codes into code-clusters (sub-themes)
At this stage of the process, the researcher is encouraged to think about the codes in relation to one another, to cluster codes that can be logically combined, or that share meanings or references (Boeije, 2002) or to look for connections between them (Willig, 2008) – here the researcher is asked to imagine a magnet pulling some codes together (Smith & Osborn, 2008). More broadly qualitative researchers are generally encouraged to organise codes into groups at a different level of abstraction (Elliot et al., 1999) or to consider how codes that share a relationship can be linked to create coherent categories (Green et al., 2007). Miles and Huberman (1994) liken this to a statistical factor that groups material into a more coherent whole. In other instances, the researcher is asked to consider whether the relations between codes are hierarchical and whether such codes should be ranked (Willig, 2008). The researcher is encouraged to assign names to these code-clusters that capture their essence, and these code-clusters are considered sub-ordinate themes (Willig, 2008) – hereafter referred to as sub-themes.
For practice codes, this task was relatively straightforward. For example, the following codes were clustered: ‘providing participants with counselling for HIV onsite’, ‘referring for ART’,
‘encouraging participants to take up HIV care’, ‘drafting comprehensive HIV treatment plan for participants’ and ‘establishing HIV treatment fund for participants’ and assigned the code- cluster name of ‘Taking steps to help address participants’ HIV needs’. The same relatively straightforward identification and clustering of practice codes was undertaken for STIs and other needs (contraceptive needs, pregnancy needs, and general conditions) for both participants and volunteers. For the sense-making or perceptions codes, this task was more complex, but began with the creation of codes such as ‘responding to risk assumption’ and
‘responding to effort’ which began to capture respondents experiences that, by taking steps to help, they were reciprocating for valued contributions. These code-clusters constituted preliminary subordinate themes (Willig, 2008).
It was been noted that a theme represents ‘some level of patterned response or meaning within the data set’ that captures some significant aspect of the data in relation to the study question (Braun & Clarke, 2006, p. 82). Others have described a theme as ‘a recognizable configuration of meanings which co-occur in a way that is meaningful and systematic rather than random and arbitrary’ (Willig, 2013, p. 59). Efforts were made - at this early stage – to ensure that code-clusters were a coherent constellation of sense-making first-level codes.
The first series of interviews were all with site-staff, who were working at two of the five sites conducting trials across the country. Practices about how sites were implementing strategies to address the medical needs they identified were compared and contrasted. This task would continue for the remainder of the interviews with site-staff until a cross-site account was generated of site-staff practices for HIV care, sexual and reproductive health care and general care (cf. Quinn Patton, 2002a).
3.3.9.5 Step 5: Developing theme tables for individual interviews
It is recommended that qualitative researchers use visual aids to help them to organise their codes into sub-themes (Braun & Clarke, 2006) – that is, researchers are encouraged to use aids to help them conceptualise patterns in the data and the relationships between them
(Braun & Clarke, 2006). In IPA, it seems a particular kind of visual representation is recommended, namely a table and it is recommended that after each interview the researcher develop a table that visually displays ‘codes’ structured into sub-themes (Willig, 2008).
Therefore, for each interview, a table was developed that included extracts labelled with particular tags (codes) clustered into code-clusters. The tables also showed anonymised participant identifiers, as recommended (Willig, 2008). These tables reflected first-level codes clustered where they shared meanings (Willig, 2008).
3.3.9.6 Step 6: Developing themes tables across interviews
After about every three interviews, individual theme tables were studies for shared experiences and a master theme table was developed that represented first-level codes clustered into code-clusters (sub-themes) for all the interviews. Sub-themes were also clustered to develop over-arching themes (Braun & Clarke, 2006) or master themes that tried to capture shared experiences of the phenomena under investigation (Willig, 2008). For example, one such master theme table (originally named ‘Seeing differences’ in care but eventually named ‘Privileging’) visually represented various code-clusters (sub-themes) from multiple interviews concerned with differences in care between participants and citizens as well as between participants at different sites and related tensions and ambivalences.
3.3.9.7 Step 7: Coding documents
At this time, many relevant documents had been obtained as a result of the engagement process outlined earlier. These included master protocols (forwarded from the network) and actual protocols, informed consent forms, participant information booklets, site ART plans, as well as ethics application forms that accompanied protocols when these where submitted to RECs, as well as letters of correspondence to and from RECs (forwarded from participating sites). These documents were not drafted using the rich dense perspectival language used by interviewees, however, they comprised a useful source of information about the controlled language used in more ‘official’ documents. For such documents, annotations were made according to the party referred to (volunteer, actual participant, participating community) and need being referred to (HIV, sexual and reproductive health care, other) and assigned first-level practice codes. These were subsequently clustered according to whether they
which master themes coded documents would inform, however, they were subsequently used to inform the master themes ‘Reconciling’ and ‘Privileging’.
3.3.9.8 Step 8: Continuing coding of subsequent interviews
Codes from previous interviews were used to orientate the coding of subsequent interviews, while additional codes were added (or elaborated) in line with recommendations to identify repeating patterns as well as newly emerging issues (Quinn Patton, 2002a; Smith & Osborn, 2008). This allowed the development of a successively integrated list of codes (cf. Willig, 2008) that tried to reflect an open mind while recognizing the inevitable influence of previous coding (cf. Lavie & Willig, 2005). The process described above was undertaken for transcribed interviews with representatives from other stakeholder groups.
3.3.9.9 Step 9: Continuing to structure codes into subthemes and master themes
As set out in an earlier step, tables for every interview continued to be developed setting out coded extracts clustered into code-clusters (sub-themes). Also master theme tables continued to be developed that meaningfully encapsulated various sub-themes (cf.
Alexander & Clare, 2004, p. 74). Master theme tables contained all the codes, quotes and participant identifiers, clustered into several sub-themes from across all interviews. These master theme tables were not merely visual representations of prior coding and clustering.
Rather, they enabled that process to take place more precisely. Working with these master theme tables allowed a detailed examination of each text-extract tagged with the same code, and convergences and divergences between them. This was akin to ‘analysing codes’ (Braun
& Clarke, 2006, p. 89). Considering the relationships between codes, sub-themes, and master themes led to some reorganizing and renaming aspects of the coding structure at this point.
Sub-themes are considered useful for giving structure to large and complex master themes (cf. Braun & Clarke, 2006). In this analysis, each master theme comprises of four or five sub- themes nested within the master theme. This was akin to grouping together closely-related sub-themes into higher-order themes (cf. Clare, 2002) or identifying where a higher-order theme encapsulates lower-order themes meaningfully (Alexander & Clare, 2004). In Appendix 4, there is a summary of codes clustered into subthemes and master themes.
The twenty-one interviews plus six additional transcripts provided the co-researcher (as set out earlier) formed the primary information for this analysis. Supplementary data comprised text excerpts from additional interviews on prevention modalities conducted by a co- researcher where care-related concerns were mentioned.
It has been noted that there is no correct number of participants for a qualitative study (Smith
& Osborn, 2003 in Brocki & Weardon, 2006). The danger with larger samples or a large analytical base is losing subtle meaning inflections (Smith & Osborn, 2003, in Brocki &
Weardon, 2006). This danger was countered by generating detailed codes that would capture subtly different manifestations of the sub-themes to provide for sufficiently textured over- arching themes.
Following the steps outlined above led to the development of three over-arching themes fairly smoothly. It took much longer to develop two other over-arching themes. The over- arching themes did not all develop simultaneously.
3.3.9.10 Step 10: Naming master themes
In order to find a name that seemed to capture the overall quality of the over-arching themes, the overall structure of the master theme tables was examined and various titles were experimented with to see how well they rendered the texture of stakeholder experiences. For example, for the theme ultimately entitled ‘Privileging’ the title ‘Seeing differences’ was originally assigned, revised to ‘Adjudicating differences’ because it seemed that many of the sub-themes were concerned with perceived differences between various parties, for example, between participant and citizens, or between participants at one site versus participants at other sites. However these titles seemed too neutral - as if the experience was merely about noticing differences or managing them somewhat clinically - whereas many sub-themes captured ambivalence between interviewees, and within interviewees, about advantaging some parties over others – an overall quality of their experience that was more effectively captured by the title of ‘Privileging’.
3.3.9.11 Step 11: Writing master themes into a narrative
At this stage the researcher is encouraged to write a detailed description for each theme (Braun & Clarke, 2006) and translate the themes into a narrative account where these are illustrated and nuanced. It is recommended that visual aids are used to generate an analytic commentary interspersed with verbatim extracts (Braun & Clarke, 2006; Smith & Osborn, 2008). The researcher should provide a convincing account of the nature and quality of the participants’ experience of the phenomenon under investigation (Willig, 2008). The researcher should identify the story that each master theme tells and how it fits into the broader overall story being told (Braun & Clarke, 2006).
The five master theme tables were used to structure a narrative account. This was developed by moving back and forth between the data as represented in the master theme tables and the narrative account to assess whether all the sub-themes were being adequately represented. This was considered a ‘conceptual web’ including larger meanings and their constitutive characteristics (Miles & Huberman, 1994, p. 63). Quotes were selected that supported the analytic point (cf. Braun & Clarke, 2006) and that represented the most articulate expression (Brocki & Weardon, 2006). ‘Editorial elision’ in quotes was represented by using the convention of (…) (Smith, 1999, p. 286).
At this stage of writing up the narrative account cycling back to earlier stages took place in the form of checking whether text had been accurately coded and meaningfully clustered.
This reflects the observation that analysis is recursive, not linear, where the researcher has to move between coded data extracts and the analysis being written, and that writing is an integral part of analysis (Braun & Clarke, 2006). All the data extracts were examined to check if they were collated systematically in relation to a particular sub-theme and in relation to an overall master theme (cf. Braun & Clarke, 2006) to make sure that constituent sub-themes as well as emerging master higher-order integrative themes were grounded in the transcripts (cf. Willig, 2008).