Key Informant Interviews

The first phase of the research involved undertaking qualitative interviews with key informants. Qualitative interviewing begins with the assumption that the perspective of others is meaningful, knowable and able to be made explicit (Patton 1990). The purpose of this research is not only to know what Māori think of current performance measurement and contracting frameworks but by capturing their perspectives, use this knowledge to improve those frameworks. Face-to-face, in-depth, semi-structured interviews were undertaken with key informants as one means of capturing this knowledge.

There are a number of advantages to face-to face interviewing, both from a western perspective and from a “Māori-centred” perspective. Rice and Ezzy’s description of a good interview being “like a good conversation” best characterises the type of interview

I was striving to conduct with both key informants and providers (Rice and Ezzy 2002, p.51). Rice and Ezzy (2002) note that in good in-depth interviews, the good interviewer works hard at listening, as careful listening allows the interviewer to ask questions which make the respondent think and in turn, expose what they do and how they do it. Stokes, in writing about Māori research states that the researcher who has learned to listen quietly will “learn more and so be more effective” (Stokes 1992, p.11). From a Māori-centred perspective the face-to face interviewing resonates with the cultural imperative to undertake exchanges between people kanohi ki te kanohi; literally face to face. Face to face interviewing has found favour amongst a number of Māori researchers in the past not only because of the personal nature of the method but also because of the importance Māori place on the researcher being accountable to the research participants (Milroy 1996). In order to be true to both the intent of the research, and to myself as a Māori researcher, face to face interviewing was not only methodologically the best way to collect data, but in keeping with the values of the project.

The semi-structured interview was again used for the benefits the method brought to the project. Using an interview schedule yet being flexible about that schedule allowed respondents to develop and work through their own ideas and speak widely on issues (Denscombe 2003). The use of the semi-structured schedule allowed previously unthought-of connections and themes to emerge and resulted in a very rich dataset. Bowling (1997) notes that in semi-structured interviews, interviewers are able to probe fully for responses, more information of greater depth can be obtained and response rates are generally higher than with postal or telephone interviews. According to Polit and Hungler (1995), the semi-structured interview is best used when the researcher wants to be sure that a given set of topics is covered in the interview, so that themes across interviews can be tracked, yet is open enough to allow for outlying views to be expressed.

An interview schedule, based on the literature review and consisting of a range of open- ended questions, was devised and tested on a former Māori mental health worker in April 2003 for clarity and ease of understanding. Minor amendments were made to the schedule so that it could be administered more easily at the interview. The final schedule comprised twelve main questions used to “guide the interview” although

questions could be dropped and new ones added at my own discretion, depending on the expertise and knowledge of the key informant. The use of a base interview schedule did however ensure some level of consistency across interviews. Key informant interviews took place between August 2003 and February 2004. From these interviews, other key informants were identified which required a further round of “mop-up” interviews in June and July of 2004. In all a total of twenty individuals were interviewed including the pilot interview.

Key informants interviews took place in a venue that was agreeable to the participant. Often this required traveling and meeting with key informants in their place of work, however some interviews were done in my office at Massey and yet others done in the key informants’ home. Interviewing usually took between 45 and 90 minutes and began with an introductory phase where I introduced myself and my whakapapa as well as the research. Grbich refers to this time prior to the interview proper as the “settling-down” time, where the nature and purpose of the research and the interviewee’s rights may need to be recalled (Grbich 1999, p.98). Indeed it was during this part of the interview I ran over the information sheet and consent form, ensuring that the latter was signed prior to the start of the interview. Once this breaking of the ice” had been achieved the interview proper began. During the interview key informants were asked about their understanding of performance measurement and performance standards and how these are promulgated, applied and implemented within the public service and in health. They were also asked about how the performance of Māori health providers is assessed, what criteria should be used when assessing the performance of Māori health providers, and what role a ‘cultural’ performance measure might have in an overall performance measurement system. At the conclusion of the interview key informants were given the opportunity to clarify anything about the research and asked whether they could suggest other experts in the fields of Māori mental health and performance measurement whose knowledge and expertise might benefit the study. Key informants were given a card and koha in acknowledgement of their gift of their time and the interview was concluded.

Interviews were taped (with permission), and transcribed as soon after the interview as possible. Transcribing was done on both analogue and digital transcribing equipment, by three separate people. Each of these people was required to sign a transcriber

confidentiality form to ensure the confidentiality of the material collected (Appendix 7). Transcriptions were sent back to respondents for checking, either in hard copy form, or electronically. While this was an important part of remaining accountable to the participants, only one of the key informants made extensive changes to their script. Changes, when made at all, included correcting names and grammar. Transcripts and tapes were identified by code only; all identifying information was removed after the transcripts had been checked by participants. Codes were kept in a locked drawer, separate from the tapes and the transcripts, at my office at Massey University.

A preliminary analysis of the interviews was undertaken prior to the second stage of fieldwork, the interviews with providers. This preliminary analysis resulted in the creation of a table which outlined in summary form, the major reasons key informants gave as to why Māori mental health providers might deliver over and above their contracted outputs (Appendix 8). This table was used in the second phase of the research: interviews with providers.

Phase 2 – Interviews with Providers

The second data collection phase of the research involved interviews with Māori community-based mental health providers who held one or more mental health contracts with the Ministry of Health, DHB or other funder (eg: MDO).

Once again face-to-face, in-depth, semi-structured interviews were undertaken with providers. However unlike the key informant interviews which tended to be conducted solely with the researcher and the individual key informant, providers were informed prior to the interview that group interviews were more than welcome. Interview schedules were sent out to the providers ahead of time, so that they had the opportunity to prepare responses and the number of people at the provider interviews was then left to the provider to determine. For example, in the case of one provider, a manager and a member of the Board participated in the same interview, while at another provider, the manager and two staff members participated in the same interview. My rationale in allowing the opportunity for group interviews was to take as little time as possible from the providers, who I knew to be busy with their own work. I was very thankful to those providers who did agree to participate and therefore wanted to make the burden of being interviewed as painless as possible. Using group interviews had both positive and

negative points. On the positive side these interviews tended to be more dynamic, vibrant and wide ranging in their scope. By the same token however these more dynamic interviews were also the most difficult to transcribe.

The provider interview schedule was derived from the literature and from the preliminary analysis of the key informant interviews. A “test” interview schedule for providers was used in the first provider interview completed in August of 2003. This interview was undertaken early in the fieldwork (indeed key informant interviews were only just starting), because the provider volunteered to be interviewed at the consultation hui (as discussed above). Because the provider was so keen, and because I had the time, I decided to strike while “the iron was hot” and go ahead and conduct the interview, using a then draft schedule. This schedule became the basis of the provider interview schedule used in the remaining interviews.

The schedule comprised thirteen main questions and, as with the key informant interview schedule, questions could be dropped and new ones added as necessary. In addition to the interview schedule all providers, apart from the first provider interviewed in August 2003, were also asked to comment on the table derived from the preliminary analysis of the key informant interviews (ie: reasons as to why Māori mental health providers might deliver over and above their contracted outputs). Providers were asked whether they agreed or disagreed with the reasons key informants had given, what if anything they would add and whether any reasons had been omitted.

Provider interviews, with the exception of the August 2003 interview, took place between June and October 2004. In all a total of seven providers, comprising a mix of some 15 staff and board members, were interviewed. Providers were asked whether there were any tangata whaiora or whānau members who may have wanted to participate in the research. I had made sure in my ethics application to note that tangata whaiora may be participating interviews and had given consideration to the processes and procedures necessary to ensure the safety of all participants. However no tangata whaiora volunteered to participate and as a result these processes and precautions were never invoked. Provider interviews invariably took place at the provider’s place of business. According to the type of provider, this might have been a health centre on, or attached to a marae, a converted private residence in town, or in an office block.

Provider interviews lasted between 45 minutes and 2 hours and usually began with morning tea, which I brought with me. During the morning tea I would reiterate the research, its purpose and answer any questions that the provider might have. I found this time to be particularly valuable, both for making whakapapa and other connections as well as allowing people to relax and become mentally prepared for the interview.

Provider interviews commenced with a review of the information sheet and consent form (Appendix 9). Providers were asked their understanding of how their performance was measured; whether these measures or their contracts adequately captured the extent of their work; what additional work they did do and why; and how they thought the current situation might be improved. Finally providers were asked about their accountabilities and how they knew when they were being successful as Māori health providers (Appendix 10). Providers were also given the opportunity to ask any questions they might have about the research. At the conclusion of each interview, participants were given a card and a koha.

Interviews were taped (with permission), and transcribed as soon after the interview as possible. All the tapes, research notes and hard copies of the transcriptions were kept in a locked cabinet at my office at Massey University. A protocol outlining the process for storing, retrieving, destroying and/or returning interview information (including tapes) based on the National Ethics Committee regulations governing research data was developed for participants. An example of this protocol is attached as Appendix 11.

In all a total of 35 key informants and staff and management of Māori mental health providers were interviewed for this research. In a process of triangulation the data collected in these interviews was compared with the thematic analysis undertaken of the contract and performance monitoring documentation and with the journal and field notes. This process of analysis is described in detail below.

Analysis

The analysis involved a number of stages: i) analysing the information collected in the key informant interviews, ii) analysing the information collected in the provider, interviews, iii) analysing the contractual and other documentary material collected, iv)

analysis and inclusion of field note and research journal data; v) analysis of the material as a whole. The data collection and data analysis has been developed in an iterative process allowing for theory development which is grounded in empirical evidence collected. As described briefly above, as key informant material was collected, a preliminary content analysis was undertaken in order to formulate the questions for the provider interview schedule. The preliminary findings regarding “reasons for overprovision” were also used during interviews with providers in table form. As provider material was collected and analysed, themes and theories were developed and noted in the research journal for further analysis at the conclusion of the fieldwork.

Content analysis was the primary analytical process used with the interview transcripts. Content analysis (Patton 1990; Crabtree and Miller 1992; Yin 1994), allows for a careful description of the data and the development of categories in which to place processes and behaviours. In content analysis the data are organised around key themes and further examined to see how well the data fails or fits the categories. Because data are analysed as they are collected (i.e. after transcription) theories or patterns may be developed and further explored in successive cycles of data collection and analysis. It is also possible to examine data at this stage for potential sources of bias and inconsistencies which can be selectively explored in the following collection phase.

The interviews with key informants and providers were initially analysed by defining broad categories derived from the interview schedule, reflections on the literature and, in the case of provider interviews, the interviews with key informants. Interview notes were reviewed and coded according to these categories and new themes were sought. Previously coded interviews were re-coded as new themes emerged. The themes arising were then interpreted and the notes from each interview reviewed in light of the interpretations, to see if anything had been omitted.

Coding and analysis of data was done both manually and using NVivo, a specialist software package for qualitative data analysis. NVivo is particularly helpful when dealing with large transcripts and managing large quantities of qualitative material. It is also invaluable for fast and accurate retrieval of previously coded material. The majority of the interview transcripts were coded, stored and managed in NVivo. The remainder of the transcripts were coded and managed manually.

The analysis of the contract and performance measurement documentation was done manually, again using thematic content analysis. Documentary material was accessed from six of the seven providers that participated in the research. Of the seven providers, one declined to release any documentary material, citing commercial sensitivity, while a further service provided performance monitoring material, but declined to release contractual material, again citing commercial sensitivity issues. Providers were asked to provide a current mental health contract for the purposes of this research and it was up to the provider to choose which contract to make available. Some of the smaller providers only had one mental health contract with a funder, while other larger providers simply selected one of the range of contracts they had, for use in this research.

The coding frame for this material was derived from interviews with providers as well as by a preliminary analysis of the contracts themselves. Contracts were analysed by type of contract, type of language used (including jargon), complexity and ease of use, while performance monitoring documentation was reviewed primarily for examples of monitoring information collected and the types of information reported in the narrative section.

Interview transcripts were also analysed against the field notes and entries in the research journal. Field notes were written up immediately after each interview and contained information about how well I regarded the interview to have been conducted. For example field notes may have included my perceptions on how comfortable the participant was in answering the schedule, areas to explore in subsequent interviews or even areas of weakness in my own interviewing technique. Field notes also contained extra material that may have been said after the tape had been switched off, but which was still relevant to the research and my own reflections on the content of the interview that had just been carried out. The research journal contained similar information as my field notes as well as factual material about interview times, locations and during the course of the provider interviews, material about the service itself. The research journal was also used to note undertakings I had made to any of the participants which needed to be followed up at a later date. Both the field notes and the research journal material augmented the interview data and were analysed for additional themes or insights into the research. An example of a journal entry is contained in Appendix 12.

Once the initial analysis had been completed findings were fed back to the participants for comment. The feed back stage was a crucial part of the study as it fulfilled a number of functions. It allowed the participants to remain involved in the research and preserved a sense of ownership in the results. It also afforded participants the opportunity to provide comment, clarification, or additional information on the research. Finally the feed back stage provided an opportunity to regard the analysis with “fresh eyes”.

A critical component of the research is the production of a Māori analysis of the data. While much has been written about Māori methods, ways of collecting data that are