Interpretative Grounded Theory

The study for this thesis was guided by an interpretative epistemology, an approach which postulates that human beings “are complex, unpredictable and reflect on their own behaviours” (Green and Thorogood, 2004, p i 2). Interpretive studies attempt to understand phenomena through the meanings that people assign to them, how phenomena are influenced by context, and how context influences the phenomena (Locke, 2001). Grounded theorists working within an interpretive paradigm typically adopt a reflexive stance believing that the researcher, his/her knowledge, beliefs, values, and interaction with participants will influence the interpretation of data. Theoretical analyses are thus interpretative portraits of a reality, not objective reports (Charmaz, 2006).

Table 3.1: Kev Features o f Selected Models of Grounded Theory

Author Summary of the analytical procedures and

f

variations of terminology

Comparing incidents applicable to each category Integration categories and the properties

Note, develop and follow up links between categories Consider the conditions under which the links hold Make connections to existing theory

Use extrem e comparisons to the maximum to test emerging relationships.

Moving towards parsimony through the determination of a core category recycling earlier items in term s of a core category

Explanatory matrix a s corner stone

Z>

Emphasis on using diagrams, charts during analysis

Creating and refining the research and data collection questions

Raising term s for concepts Asking more conceptual questions

Make further discussions and clarify conceptual thoughts through writing and rewriting

*<

CDto

delayed Social constructionist

3.4 Sampling

Traditional grounded theory (Glaser and Strauss, 1967) requires that the study sample should target those most likely to inform the emerging theory. This is known as theoretical sampling. Theoretical sampling itself, however, needs a starting point (Charmaz, 2006).

Maximum variation was sought on the basis of three variables, age, socio-economic deprivation, and type o f community. Capturing variation in ages was an important consideration because it is known that beliefs and values are not static but evolve over the life course (Sheldon, 1998), and therefore it was likely that different generations would have varying relevant attitudes and experiences and the level of community deprivation was considered important because o f variations in socio­

economic influences on health (previously mentioned). Finally it was felt that in South Wales urban, rural and post-industrial areas (valley) communities differ in relation to cultural identity (Dicks, 2000).

Three key groups of antibiotic consumers were identified: children under 5 years of age; adults of working age (those considered legally adults i.e. over 18 years old and those under the lowest retirement threshold required for receipt of the UK state pension) and older adults (those who had reached retirement threshold or where older) (Table 3.2). Children under 5 years of age, and older adults were of interest because they consult most frequently for CRI and are prescribed the greatest number of antibiotics (McCormick et al, 1995; Wrigley and Majeed, 2002). Although adults of working age are known to receive fewer prescriptions of antibiotics compared to other age groups. Working age adults constitute the largest number of antibiotic

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users (because they account for the largest proportion o f the population) (Wrigley and Majeed, 2002). Studies measuring antibiotic prescribing rates in relation to contact (consultation) within primary care report that adults o f working age received as many prescriptions for URTI as do other age groups (Akkerman et a l , 2004).

Table 3.2: The Sampling Strateev

Characteristics o f 3.4.1 Issues Surrounding Research with Children

Although the initial sampling strategy attempted to reflect the heterogeneity o f the South Wales population, children and teenagers below the ages o f 18 years were not included. Data from this age group were collected through parents. This data however, represents parents’ attitudes to their children’s health and use o f medicines, as opposed to the children’s own views. Although there is clear value in exploring children’s views, I did not gather data directly from them in this study for several reasons. Firstly, ethical and child protection issues were considered. Undertaking individual interviews with children can be problematic as lone researchers can be

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vulnerable to child protection concerns. Secondly, children may feel uncomfortable about participating in interviews, which may in turn affect the quality of the data. In addition, there were concerns about how effectively data from children could be compared to that of adults, as language and cultural reference are distinct to each group (Punch, 2002). Ultimately, the scope of the study was confined by resources and time.

3.4.2 The Socio-Demographic and Geographic Basis o f Sampling

Initially, three unitary authorities in South Wales were selected from which to recruit, one urban, one rural, and one from within the post-industrial areas of the South Wales valleys. Within these three broad areas, electoral wards were selected using Townsend Material Deprivation Scores (referred to forthwith as Townsend Scores) from the National Census (2001) to identity areas of varying prosperity.

Existing census categories o f deprived (referred to in this study as areas o f high deprivation); median (referred to as average deprivation) and affluent (referred to as low deprivation) were identified. Within each unitary authority three electoral wards were selected, one from each of the above categories.

Consideration was given to the location and proximity of each ward. In order to maximise homogeneity within the selected ward, wards surrounded by areas of similar economic status were targeted. It was hoped that this would make it more likely that the members of the community groups reflected the general socio­

economic status of that particular area.

Polit and Beck (2006) suggest that lack of planning can constrain flexibility within research designs. The initial sampling strategy was valuable in enabling detailed planning for recruitment. I was able to select appropriate electoral wards and draw up a list of community gatekeepers at an early stage. Intricate planning, however, gave me the impression that recruitment would be a smooth, systematic process. In reality, waiting for responses from community group ‘gatekeepers’ and volunteers (recruitment is discussed in section 3.4.5) left my aspirations for a smooth

recruitment process unfulfilled. It proved difficult to recruit from some pre-specified groups, for example working age adults from electoral wards of low deprivation and rural areas of high deprivation. As a result, I did not meet my objective of maximum variation outlined in Table 3.2. I was also aware that collecting data according to a pre-planned route had the potential to force the analysis into irrelevant directions (Strauss and Corbin, 1998). However, beyond the decisions concerning the preliminary purposive sampling, delayed theoretical sampling was undertaken.

Theoretical sampling involves exploring data, constructing theoretical hypotheses and then re-examining initial ideas through further data collection. In this sense theoretical sampling involves both inductive and deductive reasoning (Charmaz, 2006). Charmaz (2006) describes the particular form of reasoning used during grounded theory as ‘abductive’. “Abductive inference entails considering all possible theoretical explanations fo r the data, forming hypotheses fo r each possible

explanation, checking them empirically by examining data and pursuing the most plausible explanation ” (Charmaz, 2006, p i 04). (Delayed theoretical sampling is

discussed further in section 3.7.5)

3.4.3 Recruitment

Once geographical areas had been selected I planned to recruit individuals with characteristics consistent with those defined by the initial sampling strategy. Using the Internet as a resource, unitary authority and other local websites were searched to identify existing community groups and clubs. Letters were then sent to group leaders explaining the purpose of the study and asking permission for me to attend a group meeting in order to explain the study and invite potential respondents to participate in person.

A wide variety of organisations were approached, for example, mother and toddler groups, sports clubs and community education centres. Appendix 2 describes the community groups approached and the nature of the approaches. In the later stages of the study, community groups were purposively selected because of their

likelihood to have members possessing the characteristics sought during theoretical sampling. For example, when I wished to target young men I approached football clubs.

Gaining access was a time-consuming activity. Initially, I hoped to visit groups in close proximity to each other or within easy travelling distance, within the same day, thereby reducing travel time and costs of fieldwork. As things turned out, I often travelled long distances to recruit respondents at the convenience of the group leader, even if it meant large detours or travelling back and forth to the same town several times during the same day. ‘Gaining access’ was not a single event, but was constantly re-negotiated, and often required multiple letters, telephone conversations

or making appointments to meet with gatekeepers to discuss the study in person.

Once permission from the group leader was obtained, I was able to canvass for willing respondents. Gatekeepers acted as my ‘sponsors’. They helped bridge the gap between myself and group members by initiating early introductions. Their support in recruitment was invaluable, as the extract below illustrates.

(Excerpt from Field Diary 03/04/06) (Recruitment at a playgroup)

The leader o f the group called fo r quiet and addressed the mums in the room,

introducing me as ‘Nurse Nancy ’. She explained that I was looking fo r mums to talk to me about what it was like when their children had colds. She then thrust a cup o f tea in my hand and I moved around the room introducing myself to small clusters o f mums, giving out information/recruitment packs and answering questions.

Having gained access to a community group I introduced the study and myself in person. I asked potential respondents to take information packs and to contact me if they felt that they might be willing to participate. Information packs contained a letter of invitation and written information about the study (Appendix 3), a ‘potential participant reply slip’ (Appendix 4), and also a university-addressed envelope.

Recruiting in person seemed to have some unanticipated benefits. Participation in the study appeared to be encouraged by my own enthusiasm.

(Excerpt from Field Diary 21/4/06). {Second visit to playgroup)

I was asked about the success o f my earlier recruitment activities. Having said that I had had several responses, the playgroup assistant said “Fm not surprised; you can see how enthusiastic and committed you are, ju st by your face and listening to y o u ”

This encouraging comment stayed with me throughout the recruitment phase of the study and spurred me on whenever I felt that I didn’t have the energy to face another group o f strangers. Attending group meetings in person did, however, have some disadvantages. On occasions members of community groups made incorrect

assumptions about the reason for my attendance and, as a result, some were

unreceptive to my recruitment efforts. For example, during a visit to one playgroup a small group o f three mothers displayed body language which suggested that they objected to my presence. When I approached this small cluster of mothers, one mother commented that she had thought that I was trying to sell something. In order to reduce the risk o f my presence at group meetings being incorrectly interpreted, group members were provided with prior warning and information about my

recruitment visits whenever possible. Posters were distributed at community centres and information about my visit was included in community newsletters.

Although face to face recruitment was the aim, this was not always practical. Some groups, for example, a municipal golf club and did not have regular group meetings.

In these cases the managers were asked to distribute information packs to group members and I then waited for responses. This strategy had limited success. Figure 3.1 summarises the recruitment process and quantifies the number o f community groups approached, information packs distributed and responses received from those willing to participate in the study.

Recruitment commenced in the areas closest to my base and then, as the study progressed, expanded to other areas o f South Wales. Starting ‘close to home’ was beneficial in minimising the amount o f time I spent out in the field alone while my confidence in finding new places and interviewing strangers developed. It also meant that, if I had needed to, I could have rapidly returned to my base to sort out any technical problems, such as equipment difficulties. Whilst this did not occur, it was a valuable emotional prop in the initial stages o f the study.

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Young adults (under 25 years of age) (identified as a target during theoretical sampling) from rural and post-industrial areas of high deprivation were particularly difficult to recruit. Many of the gatekeepers of community groups from areas of high deprivation did not reply to my letters or other attempts to make contact.

Recruitment activities were, therefore, expanded to include a single electoral ward within the unitary authority of Caerphilly, with some success. In addition,

Townsend Scores indicated that there were no areas classified as low deprivation within post-industrial areas.

Successful recruitment did not always lead to data collection. Respondents sometimes changed their minds, became unavailable or failed to attend arranged meetings. This resulted in wasted journeys and on one occasion the interview was abandoned.

Figure 3.1: The Recruitment Process

Purposively selected electoral wards («=10)

Identify community groups/clubs/association (n=31) Letters to group leaders.

(Follow up letter, telephone call, or appointment with gatekeeper)

Access granted and recruitment efforts made (n=27) (Explain the study to groups and individuals)

Recruitment packs distributed (n=283)

Individuals who initially expressed a willingness to be interviewed (n=54)

Suitable Volunteers (purposive or theoretical sampling) (n=49)

Interviews completed {n~46)