Data construction

This chapter is organised into three sections. The first describes the activities undertaken before potential research participants could be contacted, including obtaining ethical approval and devising a sampling strategy. In this section I explain the rationale for selecting three local health trainer services as the focus of this research. Section two provides an overview of the fieldwork process, incorporating a description of the activities associated with recruitment and data collection. Section three sets out the practicalities of data analysis and measures taken to enhance the rigour of the study, including a description of the reflexive approach maintained throughout the research process. Although the various activities involved in sampling, data collection and analysis are described here as separate stages, in practice they occurred simultaneously in keeping with the iterative nature of both grounded theory and longitudinal qualitative research (QLR). This allowed each stage of fieldwork to inform the next, as part of the constant comparative approach. The chapter ends with a summary of the main components of the study design.

Stage one: preparing to enter the field

Ethical considerations

The first practical step towards fieldwork was to submit my research proposal and all supporting documentation for internal peer review at Northumbria University. This process was helpful for two reasons: firstly, the reviewers provided constructive feedback to strengthen the submission for NHS research ethics approval. For example, they advised that participants should be able to opt out of keeping a diary rather than using this as an excuse to withdraw from the study (discussed further in the sub-section on methods). Secondly, I was required to undertake a full risk assessment for insurance purposes and, after setting out the actions to minimise any risks, I felt more confident when entering the field. These actions included developing and adhering to a personal safety protocol at all times and reporting any untoward incidents to my supervisors. As the research involved human participants and the use of personal information, it raised a number of ethical issues which were amplified by prolonged contact with the study participants (Corden & Millar, 2007b). These included: ensuring informed consent, avoiding coercion and distress,

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Informed consent was achieved by providing potential participants with information about the research and encouraging them to consider this carefully before deciding whether or not to participate. It was made clear that there would be no penalty for those that decided not to take part or withdraw from the study at any time, and this was reiterated at each interview to reduce the likelihood of coercion. Contact details for a local Patient Advice and Liaison Service (PALS) were provided so that

participants were able to seek independent advice about the research, if desired. The risks of incurring physical harm or psychological trauma through this study were assessed as being low, but there is always the potential for participants to become distressed or feel their privacy is being invaded (Robson, 2002). I informed the interviewees that they did not need to speak about anything they did not want to and could stop the interviews at any time, either for a short break or completely. All participants were asked for their written consent to take part in the study, have the discussions audio-recorded and for the (anonymised) information to be used in published material. Consent forms (Appendices B-D) were signed at the first

interview in all but two cases, involving visually impaired participants. I read the form to these individuals and asked them to give verbal consent, which was audio-

recorded. This technique has been described as “legally equivalent [to written methods] as a record for consent but practically superior as a method” for visually impaired people (Saleh, 2004, p.310). Due to the longitudinal study design, consent was seen as an ongoing process rather than a one-off event and all participants were asked to give verbal consent at each follow-up interview.

Materials relating to this study were treated as confidential and kept secure at all times in compliance with the Data Protection Act (1998), either in a locked cabinet at Northumbria University or in a database on a password-protected computer. Where direct quotations from study participants are used, these are identified either by a job title or pseudonym only to preserve the anonymity and privacy of the

individuals and organisations involved. Having considered the above, I submitted an application to an NHS research ethics committee (REC) and attended the REC meeting with my principal supervisor to answer any queries. The study was granted a favourable ethical opinion, with no amendments required, and governnance approval was obtained from the relevant NHS Trusts. This process took place more rapidly than anticipated but delays arose from staffing changes within the NHS Trust responsible for issuing the honorary contract. Data collection was subsequently delayed by three months, although this allowed additional time to build good working relationships with the research sites.

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Approaching research sites

To avoid misrepresenting the NHS Health Trainers Initiative by focusing on a specific delivery model, I set out to conduct the research in two contrasting local services. These were chosen from the north east of England for various reasons. First, I live and work in the region, so the travelling time to conduct fieldwork was minimised. Second, through my previous research, I had good links with the regional health trainer lead as well as several of the local teams. This helped in obtaining their input to the research proposal in order to ensure its relevance for developing policy and practice. Third, I was aware that conditions in the north east provide an ideal opportunity to conduct research on health inequalities. The health of people in the region is generally worse than for England as a whole, with the worst levels of deprivation and life expectancy, as well as the highest rates of binge drinking, adult smoking and early deaths from cancer (NEPHO, 2011). In 2005, nine of the region’s 10 primary care organisations were allocated funding to implement health trainers before the initiative was rolled out nationally.

I had previously mapped the nine local health trainer services onto a framework that was developed during a review of the evidence base (Visram & Drinkwater, 2005; Visram et al., 2006). The framework broadly classified the services in two ways, according to whether they: 1) addressed generic health issues or focused on a specific target population; and 2) primarily utilised one-to-one approaches or delivered activities at group or community level. This exercise allowed me to select two contrasting models for the purpose of the present study. Site A12 was identified as adhering most closely to the targeted, one-to-one model described in the

Choosing Health white paper, whereas Site B builds on a pre-existing community

development-oriented model. These two sites provided an ideal opportunity for a type of ‘natural experiment’ to enhance understanding of the underlying processes by which contrasting health trainer models influence outcomes (Pawson & Tilley, 1997; MRC, 2011). However, due to limited capacity within the team at Site A, the decision was made to add a third research site. Following discussions with the regional health trainer lead, Site C was identified as offering potentially interesting insights that might contrast with Sites A and B. The health trainers in Site C deliver gym-based exercise interventions to people referred for existing health conditions. All three health trainer services are based in areas of multiple deprivation and provide an excellent basis for comparative analysis.

12

The names of the research sites have been omitted to preserve the anonymity of individual service users, staff members and organisations.

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Following an introduction via email by the regional health trainer lead, I arranged meetings with the managers in Sites A and B to discuss and gain their support for the research. Both managers were enrolled on courses delivered by colleagues at Northumbria University and I feel that the good reputation of the University added credibility to the study. Furthermore, several team members in Site A knew me through the research conducted for my Masters degree, and I had previously worked with a key stakeholder well-known to the team at Site B. I believe these were enabling factors in establishing their trust in me as a researcher and gaining their support for the recruitment of service users to the study. I had not previously met any of the team members from Site C and it was challenging to gain the trust of the manager in particular. There seemed to be some confusion about the purpose of the research and how the findings would be disseminated, with concerns about their ‘politically sensitive’ nature that I had not encountered in the other two sites. At first I worried that I had not explained the study clearly but it became apparent through the research process that there were particular issues in this site. During each of our meetings, the manager emphasised the ways in which Site C was felt to be different from other health trainer services. These differences influenced the sampling and recruitment processes, which are discussed in the sections below.

Sampling strategy

I set out to devise a sampling strategy that would incorporate representation from the health trainer teams and client populations in each of the research sites. This would enable me to obtain an understanding of the various domains of change – individual, organisational, temporal and spatial – from both the service user and provider perspective (Thomson & Holland, 2003). Furthermore, the nature of the role meant that most health trainers were from socio-economically disadvantaged communities and could therefore offer additional insights into the needs of those communities. Inclusion criteria for the study were as follows:

Over 18 years of age at the time of recruitment to the study13

A user of the health trainer service in Site A, B or C at the time of recruitment to the study or in the preceding six months

Employed as a health trainer in one of these sites at the time of the study Having any line management, supervision or co-ordination responsibility for

these health trainers

13

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Exclusion criteria were: being under 18 years of age; inability to give informed consent for any reason; having had no contact with or knowledge of health trainers; and being recruited as a health trainer but not operational at the time of the study. Only two health trainers in Site A met the inclusion criteria; one team member was absent due to ill-health, while others had not completed their mandatory training and were therefore not operational during the study recruitment period.

Within a grounded theory methodology, the processes of sampling, data collection and analysis take place simultaneously and the evolving analysis drives the subsequent selection of units of data (Baker, Wuest & Noerager-Stern, 1992). However, sample sizes in any form of qualitative research tend to be chosen for reasons that are both theoretical and pragmatic (Coyne, 1997). All five managers consented to take part in the study, which constitutes a form of convenience sampling, whilst health trainers were initially selected using a purposive sampling strategy. By sampling data from contrasting sources, the aim was to develop variation and maximise the possibilities of obtaining leads for additional data (Lincoln & Guba, 1985). Seeking a diverse sample during the initial stages of a study can also help to foster depth and comprehensiveness, as well as enhancing the conceptual power of the findings (Charmaz, 1990). Analysis of initial staff interviews provided insight into specific issues within each of the research sites, which were used to guide subsequent study recruitment. This is known as

theoretical sampling and is essential to the inductive-deductive process of grounded theory (Glaser & Strauss, 1967). For example, gender was identified as an

important issue following interviews with two male health trainers in Site C and two female participants were subsequently recruited to the sample from a team of 15 staff. In Site B, initial staff interviews revealed length of time in post to be a key issue, and the final sample included a diverse mix of new and established health trainers from a team of 17 staff. An overview of the sample is given in table 6.

I initially proposed that 15 service users14 would be recruited from each of the two original research sites during a six-month period (May to October 2009). A total sample size of 30 users was felt to be both achievable and sufficient to reach data saturation (i.e. the point where the initial ‘working’ theory stands up to all additional data) (Glaser & Strauss, 1967). This was based on the findings from a review of

14

For the purposes of this study, a ‘service user’ was considered anyone who receives support, advice or assistance from a health trainer on more than one occasion and undergoes some form of assessment that results in the initiation of a case record. This excludes anyone who has one-off contact with the service.

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Table 6: Features of the staff sample

Characteristics Site A (n=4) Site B (n=9) Site C (n=5) Totals (n=18) Role: Manager Health trainer 2 2 2 7 1 4 5 13 Sex: Female Male 3 1 7 2 3 2 13 5 Time in post:

Less than 1 year 1-5 years

More than 5 years

1 3 0 3 2 4 0 3 2 4 8 6

published studies involving grounded theory approaches, which found that saturation generally occurs between 10 and 30 interviews (Thomson, 2006). By aiming to recruit a maximum of 30 users I hoped to counterbalance the effects of any loss-to-follow-up, which I predicted would be significant given the ‘hard-to- reach’ nature of the target populations. I also wanted to design an approach where my findings could not easily be seen as arbitrary or dismissed as the story of a few individuals (Yates, 2003). On adding the third research site, my strategy was modified to aiming to sample 10 users from each health trainer service. However, this proved difficult within Site A and only six users were sampled from this service. An overview of the user sample is shown in table 7 on the following page.

The uneven sex ratio of both the staff and user samples (a total of 28 women to 13 men) is common to most health trainer services. Otherwise, the sample is relatively diverse in terms of age and occupation, although more than half of the users are over the age of 60. The aim of grounded theory research is to gain an in-depth understanding of the realities and issues at hand, rather than selecting participants based on variables such as age and gender which may be irrelevant to the

emerging theory (Coyne, 1997). A shortcoming of the sample is the lack of ethnic diversity and efforts were made to recruit individuals from black and minority ethnic (BME) communities as part of the theoretical sampling process discussed below.

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Table 7: Features of the service user sample

Characteristics Site A (n=6) Site B (n=10) Site C (n=10) Totals (n=26) Age group: Under 30 30-39 40-49 50-59 60-69 70-79 80+ 0 0 1 1 2 2 0 1 2 4 1 1 0 1 0 0 1 1 6 2 0 1 2 6 3 9 4 1 Sex: Female Male 5 1 8 2 5 5 18 8 Ethnicity: White European British Asian Mixed – White & Asian 6 0 0 9 1 0 9 0 1 24 1 1 Occupation: Employed Retired Incapacity benefit Homemaker 1 3 2 0 5 2 2 1 1 7 2 0 7 12 6 1

Stage two: conducting fieldwork

Sample recruitment

As a result of my prior research experience, I was aware that meeting potential study participants in person tends to be a more effective recruitment strategy than simply distributing written information. This is particularly the case with individuals from disadvantaged communities who are more likely to have low literacy levels and little knowledge of academic research (Sixsmith, Boneham & Goldring, 2003). Furthermore, they may exhibit a wariness and mistrust of ‘officialdom’. Time and effort is required to build sufficient trust and legitimacy with these communities, as well as working with gatekeepers who are supportive of the research (Hemmerman, 2010). The service managers acted as gatekeepers in this study and, on the whole, were very helpful in recruiting staff and service users to the sample. Due to the lack of any local or national evaluation of health trainers, they were keen to obtain in- depth feedback on their services and were particularly interested in the longitudinal aspect. However, as stated previously, the manager at Site C expressed concerns

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about the ‘politically sensitive’ nature of this feedback and was keen to exert a high degree of control over the research process. My intention was to attend a team meeting in each site in order to explain the purpose of the study and what would be expected from the health trainers if they decided to take part. I hoped to deal with any queries or concerns about the research, and also obtain their feedback on draft study information for users to ensure its readability. The managers at Sites A and B were wholly supportive of this suggestion and the team meetings were invaluable in gauging staff attitudes towards the research.

The manager at Site C expressed a preferrence for identifying team members based on a combination of the sampling criteria and their workloads, to avoid burdening particular individuals. It is not uncommon for gatekeepers to attempt to influence the research process by recommending only participants ‘approved of’ by themselves (Sixsmith, Boneham & Goldring, 2003). Although this does not follow the principles of purposive or theoretical sampling, I felt it was more important to follow the manager’s advice and avoid creating barriers to accessing this site. Each health trainer received an information pack containing an invitation letter addressed from their manager (Appendix E) and an information leaflet explaining the purpose of the study (Appendices F). Managers received separate information (Appendix G and H). They were asked to contact me using the reply slip included in the pack if they were interested in taking part, and arrangements for an initial interview were then made by telephone or email. Due to the risk of coercion, I spent time at the start of each interview reiterating the requirements of the research, informing staff that only anonymised information would be fed back to managers, and asking for their informed consent. It became apparent that some staff had been asked to participate by their managers, rather than volunteering of their own accord, and I made every effort to reassure them that they were free to withdraw from the study at any time. None of the health trainers chose to withdraw at this stage.

In order to comply with the requirements of the Data Protection Act (1998), I was not permitted to access service user contact details and therefore recruitment of this sample took place via the health trainers. An advantage of this approach is the potential for the researcher to be perceived as a ‘friend of a friend’, which can help to even out inherent power relations (Sixsmith, Boneham & Goldring, 2003). My intention was that users would be recruited by their health trainers as soon as possible after accessing the service and selected for inclusion in the study using a theoretical sampling matrix. Health trainers were asked to approach service users at

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their first or second session of the intervention and invite them to participate in the research. My rationale for recruiting users at this early stage was to avoid having to rely on retrospective accounts of their motivation for accessing the service and first impressions of the health trainer. However, it quickly became apparent through discussions with staff that they were not comfortable with raising the subject of the research so soon and preferred to use these initial sessions to establish a rapport with users. They felt it would be more appropriate to introduce the research towards