Choice of methods and techniques

Introduction

As indicated in Chapter 2, interpretive policy analysis was used as the framework for the study. Other approaches considered in relation to the research questions were to carry out a case study or to engage in action research, and these methods are reviewed briefly in Section 1 before going on to discuss the selected method. The research questions, as described previously in Chapter 2, were exploratory in nature, which required policy analysis and qualitative enquiry using observation, document analysis and semi-structured interviews. In addition, a vignette was used to structure part of the interviews with one group of respondents, and this is also discussed in Section 1.

Approaches explored and rejected

Case study

A case study approach was said to enable an in-depth analysis of all the factors within a defined structure (Keen and Packwood, 1995). Its aims include to gain a better understanding of a situation (Yin, 2003) and to highlight areas for further exploration (Bergen and While, 2000). This might have offered an in-depth exploration of a wide range of responses from a primary care organisation to inequalities in mental health, but given the lack of discussion of this topic in the research literature reviewed in Chapter 1, there was a risk that a case study would be attempting to examine disparate activity and

incomplete knowledge. If that were to be the case not only would there be a limit to the potential data that could be collected, but the presence of a researcher uncovering this fact might have appeared threatening to a group in the early stages of grappling with complex issues. The case study approach was therefore rejected.

Action research

An alternative to a case study approach was action research which was thought might offer an opportunity to stimulate a piece of work at the same time as investigating its context and new developments. Action research was described as attempting to generate knowledge of a system while at the same time trying to change or develop it (Reason and Bradbury, 2000), and it enables the researcher to work with people rather than “on” them, drawing on practitioners’ experience (Meyer, 2000). A typology of a range of approaches to action research which moves through varying degrees of balance between the “action” and the “research” was described by Hart and Bond (1995), and the approach that would have most suited this study was that of organisational action research, since it was balanced more towards research than action. While action research would offer an opportunity to stimulate work where there might have been none, there were no accepted, evidence-based interventions for reducing or preventing inequalities in mental health. This meant that any new work would be developmental in nature and potentially difficult to define, but one of its attractions was that it would have offered an opportunity to make a contribution to the primary care organisation in return for access to study their work. The potential risks outweighed the benefits of taking this approach to the study, but the principles of making a useful contribution to the organisation and clarifying from the outset the boundaries of the researcher role were retained within the chosen method as described below.

The chosen framework: interpretive policy analysis

The framework for interpretive policy analysis adopted by the study was drawn from an account by Yanow (1999). Yanow applied the approach to health care and community work settings, which shared some similarities with the setting for this study within a primary care organisation. Yanow’s interpretive policy analyses focused on human meaning and the reality of social processes, in contrast to traditional policy analysis which addresses the objective numerical analysis of policy facts. Interpretive policy analyses can help to reframe a policy debate or to generate new policy ideas by synthesising opposing arguments rather than advising on the choice of one proposal over another as in traditional methods. Stakeholders’ interpretations of policies are

central to these analyses, since the wording of policies cannot be assumed to mean the same to everyone involved in implementation. Implementers and stakeholders are described as being from one of three “communities of meaning” of policymakers, implementing agencies and service users. Each community might also have several internal communities with different interpretations of the same policy. Yanow (1999) argued that stakeholder interpretations of policies were the drivers for change in practice rather than the policies alone.

Yanow described steps in interpretive policy analysis as follows:

ƒ Identify the policy issue

ƒ Identify the communities of meaning

ƒ Identify the discourses, that is, the meanings being communicated

ƒ Identify points of conflict reflecting different interpretations by different communities

ƒ Show implications of different meanings for policy formulation or action.

In this study, the policy issue was identified as inequalities in mental health as it might apply to primary care. The four stakeholders’ communities of meaning were taken to be (i) policymakers, (ii) primary care managers and strategic staff, (iii) frontline professionals from primary care and mental health, and (iv) a service user’s experience. Service users’ perspectives were not explored in the study, but professionals were questioned using a vignette to elicit the approaches that they might take to a service user and therefore to inentify the service a patient might expect to receive. Data were collected in different ways from each community of meaning: through document analysis of national health and social policies; document analysis of reports and strategies produced by the primary care organisation; observation of a mental health needs assessment; and semi-structured interviews with strategic staff and frontline professionals. Interviews with frontline professionals included a vignette to identify the services that a patient might expect. The methods and techniques and their application to the study are described below.

Document analysis

In an interpretive policy analysis, the researcher is interested in the ways in which the policy issue is being framed by all parties in a debate, which can be articulated verbally or in formal or informal documentation (Yanow, 1999). It has been said that any full sociological analysis must include “material traces” as well as interview data, and document analysis can provide an important element alongside other methods

(Hodder,1998). Analysis of text-based documents in a study can include documents already in existence such as policies, reports, minutes of meetings, and documents generated from the process of a study including diaries, tables and lists (Mason, 2002). Documents can also be used to help trace processes, or they can be used along with other methods of data generation. Fairclough (2003) believes that interpretations of texts as well as the texts themselves are important in researching meaning-making, therefore document analysis works well alongside interviews and observation.

Mason (2002) stated that documents are constructed in particular contexts by particular people with particular purposes and with intended and unintended consequences, and their analysis requires a reflexive process involving the author, the text and the reader (Fairclough, 2003). First, the perspective of the authors and the language or tone they apply to creating the documents is presented through production of the text, and second, the text itself is displayed using conventions and other devices to present a particular view. The third element in a document analysis is the reception of the text and the ways in which the reader makes their interpretation (Fairclough, 2003). Rather than being a passive process, reading is an activity to which the reader brings their cultural knowledge, knowledge of similar texts and their unique life experience (Atkinson and Coffey, 1997). Meaning emerges from the analysis through the relationship between the three elements, with the researcher’s own frame of reference providing the springboard for a process of dialogue between the researcher and the text (Mason, 2002).

Atkinson and Coffey (1997) recommended that an interpretive standpoint rather than a critical or judgemental stance should be taken in document analysis. They suggested that documents should be taken as data in their own right with a distinct version of social reality that can be explored through a systematic and rigorous analysis. Atkinson and Coffey (1997) also suggested focusing on the form or text and language used; the relationships between other texts and the ones under examination which they described as intertextuality; and the conventions of genre. Fairclough’s (2003) method of Critical Discourse Analysis provided more detailed guidance for analysing texts such as close reading or identifying meanings coming from the interplay between position, interests, values and intentions of the producers and the position, knowledge and values of the receivers. Different combinations of methods can be used depending on the context. For example, some texts are transparent with interpretation being straightforward while others require a great deal of thought about what is meant (Fairclough, 2003).

Another method of discourse analysis that has influenced current social policy is that developed by Foucault, which has been adapted to suit different studies such as one described by Carabine (2001). Carabine was less concerned with the ways in which discourse is structured and governed by internal rules, and more interested in how

discourse acts as groups of related statements which cohere to produce meanings and effects in the real world. She provided an example of the different ways in which lone motherhood was “spoken of” in Britain in the 1990s through speech, official texts, creative writing and practice, and the picture that could be built from these perspectives. Carabine (2001) found that interactions between different discourses could change the ways in which the issue was presented.

Two separate processes of document analysis were used in the present study. The first was to analyse nine national health and social policy documents using some of the close reading techniques and explorations suggested by Fairclough’s Critical Discourse Analysis and also drawing on Carabine’s approach to explore interactions across the policies. Reading behind the text was important in the analysis of the national policy documents to help to understand some of the influences behind the document’s portrayal of health inequalities and to identify links or conflicts within and between the policies. The process used for the policy analysis is described below in Section 2 of this chapter and the findings are given in Chapter 4. The second document analysis was to describe the context for an observation of a mental health needs assessment and to identify whether local strategies and reports influenced the primary care organisation to take action on inequalities in mental health. The process of, and findings from, the observation of the mental health needs assessment are described in Section 2 of this chapter and Chapter 5 respectively, and the rationale for the method is given below.

Observation

In addition to document analysis of local strategies and reports, data were collected from a mental health needs assessment process through observing meetings of the mental health needs assessment steering group, including the outputs from the group such as minutes, reports and emails (full discussion of the rationale for the observation is given below in Section 2). Additional interviews were also carried out with some key members of the steering group as well as other strategic staff to further explore their understanding of inequalities in mental health. Observation is said to involve the researcher immersing themselves in a research setting and systematically observing dimensions of the setting such as interactions, relationships, actions and events (Mason, 2002). The researcher has to be clear about the role they might play in that setting. For example Adler and Adler (1998) described two typographies of researchers’ potential roles as firstly, complete participant, participant-as-observer, the observer-as-participant, and the complete observer. The second typography focused on membership and described the roles as complete-member-researcher, active-member-researcher and peripheral-member-researcher. Mason (2002) suggested that the researcher cannot

always plan for the role in advance and that the role is likely to change in relation to events, and may have to be constantly renegotiated. The researcher should therefore be aware of the potential for different roles in advance, continue to be aware of them throughout the data collection, and understand their relevance in the interactions, situations and setting under study (Mason, 2002). Data from an observational study can be recorded in a variety of ways including audio and video recordings, fieldnotes and photographs (Mason, 2002). I explain my negotiated role as observer in Section 2 below.

Interviews

Semi-structured interviews were used in the study to gather data from key informants working as frontline professionals or as strategic managers within the primary care organisation. Interviewing informants is thought to be the most common method used in qualitative research (Mason, 2002). In order to access personal interpretations of events and processes, people need to be encouraged to express their constructions in their own terms (Jones, 1985), and conversational interviewing gives the informant more freedom and control of the information compared with surveys (Mason, 2002). Informants should be selected on the basis of being articulate, reflective and appropriate to the study, and can be recruited through purposive sampling by asking initial contacts to suggest further participants (Glaser and Strauss, 1967). However, the sample should be selected to test the researcher’s argument and not only to support their theories (Mason, 2002).

Qualitative interviews aim to go below the surface of a topic, explore peoples’ views in as much detail as possible, and uncover ideas that were not anticipated at the outset of the research (Britten, 1995). They also provide an opportunity to explore concepts that are not necessarily formed in people’s minds (Mason, 2002). Qualitative interviews can range from being unstructured when the researcher has little prior knowledge of a topic (Morse and Field, 1996) to being structured around areas of interest for consistency between informants (May, 1991). Semi-structured interviews lie between these and usually use a list of open-ended questions (Morse and Field, 1996) designed to enable the researcher to probe respondents’ answers (Britten, 1995). Both directive and non- directive questioning can be used to explore a subject and interviews can be carried out with single interviewees or as group interviews (Hammersley and Atkinson, 1983).

Interviewers are said to need a range of technical skills beyond the social skills required for more common forms of social interaction (Boulton and Fitzpatrick, 1994). Skilful interviewing depends on the extent to which the interviewer establishes rapport, elicits

information without controlling the interview and records information accurately (May, 1991). The interviewer is urged to plan and prepare for the interviews but must be able to think on their feet to decide how best to ask what they really want to know (Mason, 2002). Active listening is important for the interviewer in order to assess the relationship of the answers to the research focus and to plan the future course of the interview (Hammersley and Atkinson, 1983).

There should be a good balance between talking and listening, and the balance is likely to be different in each situation (Mason, 2002). Morse and Field (1996) suggest that interviews should start with small talk, a description of the interview procedures and then asking demographic information before moving on to the main issues. Questions must be open-ended, sensitive, neutral and clear, starting with the easier topics and proceeding to more difficult or sensitive ones (Patton, 1990). Most studies involving interviewing capture the interview by recording them and adding information later from written sources and field notes (May, 1991). Skills required for interviewing should not be underestimated as at any one time during an interview the interviewer may be listening, interpreting, deciding on appropriateness to the research topic, thinking about new ways to find out what they want to know, assessing body language or changes in demeanour, formulating a response, reflecting on something that was said earlier in the interview, keeping an eye on the time, checking the recorder and taking notes (Mason, 2002).

Data collected in an interview should be regarded as being unique to that particular encounter. For example an informant might feel that they had not been able to express their thoughts clearly or they might have told the researcher what they thought they might want to hear (Burnard, 1995). However, Hammersley and Atkinson (1983) believe that the inferences that can be drawn from data are more important than the issue of the accuracy of the information given to the interviewer.

The interviews in the study used a combination of non-directive and directive questions to encourage respondents to describe and explore their jobs, their knowledge and understanding of inequalities and, for frontline staff, to respond to a set vignette about a patient. The vignette is discussed below and the interview process is described in more detail in Section 2.

Vignette

A vignette was used in the study as part of the semi-structured interview to identify models of working adopted by the respondents. The vignette aimed to help to illuminate

the importance that participants gave to the social circumstances of a patient and their responses to them, in order to identify whether they were sensitive to the impact that social inequalities might have on the patient’s mental health. Vignettes are usually brief written, spoken or pictorial representations of people in situations which can stimulate more meaningful and considered answers than straightforward questions particularly when eliciting attitudes (West, 1982). Vignettes can be used both in surveys and in qualitative research (Barter and Renold, 2000). They have been used in studies of similar topics to this study such as in eliciting attitudes of general practitioners and primary care nurses to patients with psychological and physical problems (Dale and Middleton, 1990) and to patients with advance directives (similar to living wills) (Thompson et al, 2003). If used at the beginning of an interview, vignettes can help to develop rapport and facilitate a discussion around participants’ opinions and the terms they use (Barter and Renold, 2000).

A short vignette can include many references to key variables of interest to the study but there should be a balance between giving too much information that results in narrowing the scope for interpretation and too little information that leads to too many different interpretations within the study (West, 1982). In any case, the characters and storylines used for vignettes must be believable to respondents (Finch, 1987). Dale and Middleton (1990) used a vignette with general practitioners but found that vignettes lacked the interpersonal cues and background information important in real life consultations, and they were concerned that practitioners might adopt “professionally desirable” responses in order to portray themselves more favourably. The researcher cannot know what additional details are being filled in by respondents (Finch, 1987), although if vignettes are being used in a non-directive way respondents are allowed to define the situation in their own terms and can be encouraged to provide the factors that influence their decisions (West, 1982).

Turton et al (2000) used a series of vignettes to describe four potential levels of response to a primary care patient ranging from a biomedical approach with a sick individual through to a public health model. The vignette in the present study was used in a similar way to explore whether responses corresponded more closely to biomedical or social models of health. The development of the vignette and its application in the study is discussed in Section 2.

Qualitative Data Analysis

The overall aim of qualitative data analysis is said to be to transcend factual data to theoretical ideas by finding coherent patterns of ideas, thought, utterances and beliefs

(Coffey and Atkinson, 1996). In this study, grounded theory provided a framework for the