Methodological Consideration

Trustworthiness. Trustworthiness in qualitative research is an essential component of the inquiry process as it determines whether the study is credible and/or authentically represents the phenomenon of inquiry (Patton, 2002). Maxwell (2005) pointed out that qualitative “researchers are threats to the validity. The researcher’s bias and the effects of the researcher on the individuals studied, often called reactivity” (p. 108). Lincoln and Guba (1985) argued qualitative research is a matter of judging the quality and goodness. They suggested there are four criteria for establishing trustworthiness: 1) Credibility and confidence the findings are truthful. 2) Transferability, the results apply to other contexts and other participants; 3) Dependability, the consistency and logic of the data collected with the results; and 4) Confirmability, neutrality, whether the findings reflect the participants rather than the biases, motivation, and interest to the researchers.

For this study, I adopted three of Lincoln and Guba’s (1985) criteria for established trustworthiness. Credibility can be achieved using several strategies including prolonged engagement, triangulation, member checking, peer debriefing, and reflexivity. First, to ensure prolonged engagement, in which I spent 10 working days and an average of 8 or more hours each day observing the CHW program services at HFP, RHC, and MCHC. For the most part, I had complete access to CHWs’ activities. They allowed me to shadow them and to participate in all of their day-to-day activities with permission of the patients and health care team members.

Secondly, triangulation is a process wherein the researcher uses multiple sources of data to confirm themes, patterns, interpretations, and the study’s findings (Lincoln &

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Guba, 1985; Maxwell, 2005). To ensure triangulation for this study, I gathered observational data from approximately 60 individuals and I engaged in informal and formal interviews with people associated with all the three CHW programs. I documented my firsthand accounts of these observations in my field notes. I also interviewed 22 individuals, nine who were patients, family members and the other 13 who were health care professionals, working with Mary, Sabrina, and Margaret. I also included content from conversations I had with the patients and health care professionals and information from documents I collected from three sites and gathered from the literature. Lastly, I used Gay’s (2000) six attributes of being culturally responsiveness as a framework to determine the findings for RQ 3.

Third, member checking is a process that involves “receiving feedback from the respondents on the researcher’s findings. By doing a member check, the researcher can “claim the findings are valid and meet the criterion of conformability” (Schwandt, 2007, p. 187). For this study, I invited the patients and the CHWs I interviewed for the study to review their transcripts and the preliminary findings to all four of the research questions. None of the patients responded to my invitations through the CHWs; many had changed telephone numbers, some just did not respond. Two of the three CHWs responded and confirmed the findings. Each added anecdotal information that I included in the data analysis.

Fourth, peer debriefing is “the process that involved discussing the researcher’s inquiry with a group of like-minded peers to receive genuine feedback and critical thinking and consultation that will enable the researcher to think and reflect” (Lincoln & Guba, 1985, p. 308). Throughout this inquiry, I consulted a group of qualitative scholars

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at various levels of their research with the guidance of a senior qualitative research scholar. This process was very helpful in addressing issues as they arose about the research, for example, researcher bias in editing a letter for a CHW.

Fifth, as I have indicated, I am both the researcher and an insider uniquely situated in positions of power and privilege. An essential strategy that I used throughout this inquiry was the use of reflexivity. In so doing, I reflected consistently and critically on myself as a researcher, a ‘human instrument’ in qualitative research (Lincoln & Guba, 2013, p. 254). I captured these reflections through audio recording and analytical memos.

Lastly, this is an ethnographic case study. The product of this study is a rich description and analysis of CHW programs services in three primary care settings. I do not claim that my findings are generalizable to other contexts or communities, nor do they reflect all CHW programs in SC. It is essential for readers to think about the purpose of this study and the research questions before anticipating anything other than what I have described in the study design. This study is not an evaluation of SC primary healthcare system, CHWs, their employers, services, healthcare professionals, patients, or communities. It is a case study uniquely situated to represent one iteration of the services, roles, and culture of CHW programs in PHC settings in SC (Patton, 2002).

Ethical Issues. Ethical issues are a combination of factors that relates to ethics of the researchers and ethical application of the research methodologies and methods (Schwandt, 2007). The “researcher must also consider their actions throughout the inquiry process as it relates to human accountability, ethics, epistemology and politics intertwined” (p. 90). For this study, I used the research questions to explore the culture and the dynamic process of CHW program services in PHC. With this opportunity came

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many responsibilities that I took seriously. For example, before beginning and throughout the study, I tried to educate individuals about qualitative research and participant observations, as I believed many individuals think the researcher must be very distant from the inquiry. I often said I am fortunate: “I have the opportunity to learn about CHWs, so I can be a better trainer and develop a more realistic curriculum that reflects what CHWs need to know do their jobs.” As I conducted participant observations each day, I interacted with the people engaged in CHW programs at HFP, RHC, and MCHC with the utmost respect for their privacy and confidentiality, and awareness of their spaces, places, and cultural backgrounds and beliefs. I represented much of data in the people’s voices to reflect the representation of their experiences with the CHW program services accurately.

I believe an important ethical consideration is my positionality at the intersection of insider’s status. Because I am an instructor of the CHW Certification Training Program, social work, and educational courses, the CHWs, and others in the context of the inquiry often referred to me for advice. I believed some individuals might have perceived me as a threat, or having power and influence because I chose to conduct research regarding the CHW program. As I encountered individuals, I tried to establish a good rapport and minimize my role as educator and researcher. There are times during the study when my identities merged naturally to address a circumstance. For example, my role as a social worker frequently arose where I advocated for patients and the CHWs. As much as I possibly could, I asked those who asked me for advice to think through what they thought was best, and then I validated or made suggestions regarding their ideas. Still, there were times when I felt there was nothing I could do as individuals did

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think of me as an expert. During these incidents, I would say, “I think …. However, I would suggest you consult…” someone whom I believed could give them sound advice.

Another important consideration is my subjectivity and the level of reflexivity I think is required in this ethnographic case study. Lincoln and Guba (2013) remind researchers that reflexivity “forces one to come to terms with various issues related to the inquiry, the people engaged, ourselves and the multiple identities that are fluid in the research context” (p. 255). Throughout this study, I was aware of my critical lens and attuned to issues of power, racism, marginalization, and inequalities for people of color and people with low or no income that exist within all social institutions and all levels of culture. I reflected in memos my frustrations and asked questions of myself and others when I was unsure about issues related to injustice. Reflexivity requires one to ask questions of all identities, lenses, and assumptions as well as with the “binaries, and paradoxes that shape them” (Lincoln and Guba, 2013, p. 255). By writing memos, and journaling, I was able to discover things I had not thought about, and I was able to deconstruct and reconstruct meaningful experiences in the forms of narratives. Still, I believed there were times when I felt compelled to speak up, and I think I did so appropriately. At times, I sought, too, the advice of trusted colleagues and my dissertation committee members who provided me a place to vent and sound off about my concerns; they offered meaningful and useful advice that I followed as well.

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