Qualitative data collection methods

A range of qualitative research methods, including focus group discussions (FGDs) and in- depth interviews were used for this study.

111 4.8.1 Key informant interviews (KIIs)

KIIs with key informants included policy makers; programme managers and donor community (see section 4.6.1). Those at policy level within the Ministry of Health centred on policies and strategies, coordination mechanisms, information systems and accountability mechanisms and whether violence was considered a priority, what they had done so far and challenges faced. Interviews with the donor agencies included exploration around the support offered to Ministry of Health to enable it to fulfil its mandate, whether they see violence as a priority issue for the Ministry of Health and what the challenges they were anticipating are. Interviews with non-health GBV service providers included their role in GBV, and linkages with Ministry of Health. Data were collected using a brief semi structured guide. The following are the thematic areas contained in the interview schedule:

Interviewees were asked about their role in violence prevention, including what their constraints were and their organisational budgetary allocation

Health care response: They were also asked to describe their collaboration with the health sector and other stake holders involved in violence prevention and to reflect on health services provision and the facilitators and barriers to effective responses within health services. Questions on health sector policies, guidelines and protocols were included and their perceptions of the current mechanisms in place for responding to IPV in the health sector, including on capacity building

IPV: Interviewees were asked what the term means to them; what the scale of the problem is as they perceive it and what factors may be driving it in Malawi. They were also asked about the consequences of violence and what motivated them to engage in violence prevention work. What can be done: interviewees were also asked what the health care services and/or their own organisations can do to improve responses to intimate partner violence

4.8.2 Focus group discussions

Focus groups is a qualitative research method in which a moderator interviews a small group of participants, typically 6 to 10 375, and uses the group process to stimulate discussion and obtain information on the beliefs, attitudes, or motivations of participants on a specific topic

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. For many years FGDs were confined to market research but they have become an accepted method in health research 379; and in feminist research as a critical method of inquiry with marginalized groups 380. FGDs have the potential to empower participants, by raising the level of consciousness of participants about themselves and the focus group topic

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. FGDs have been found to be empowering in some research with vulnerable groups such as HIV-positive women380, domestic workers 381, 382 and domestic violence survivors 381, 382.

FGDs have been used in formative and process evaluations, informing programme development 375, understanding decision making process of patients, identifying barriers to decision making and conditions required to participate in decision making 227, 375. They can also be used to discuss sensitive topics because many people may be willing to share sensitive information through group support 223, 380. They can be also be used in combination with other methods including quantitative research. A previous study in HIV case management concluded that combining chart reviews and FGDs in their study helped them to get a more accurate and richer picture of HIV/AIDS case management than what could have been captured if they only used information obtained from reviewing charts 383.

FGDs have the potential of generating ethically problematic issues such as problems with maintaining confidentiality due to the group situation; stress; feeling of powerlessness in some participants; expectation of action and consequent frustration and the transmission of wrong information 375. An example of this is when people talk about issues that are not necessarily true but that they have strong opinions about or that are a common belief in the community. This phenomenon may include myths surrounding condoms or HIV prevention, stories about post abortion care and other IPV-related issues. The strength of feeling around issues could in turn convince other people of the truth of these myths and needs careful handling by facilitators. FGDs are not recommended for non-research purposes, when group discussions are inhibited by an improper mix of intended participants, when confidentiality cannot be assured when dealing with sensitive topics and statistics are required (detailed under ethical issues) 375.

FGDs were chosen to allow for exploration of IPV as they may enable discussions on these taboo topics because the less inhibited members of the group may break the ice for shyer participants223. FGDs were also an appropriate choice that fitted well in the Malawian context because a culture of silence is an obstacle to discussing violence experiences328, but the oral culture is still strong 384 and lends itself to the discussion of sensitive topics 385, 386.

Permission for audio taping the interviews was obtained for each focus group discussions. All focus groups were moderated by the researcher and/or one assistant under direct mentorship. Either the researcher or the research assistant (depending on who was moderating) took notes and observed group dynamics. Health care worker participants were

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informed that the research was seeking their work experiences and perceptions of IPV and not their personal experiences. FGDs lasted between 55 minutes to 2hrs.

4.8.2.1 Topic guide for discussions with health care workers

Discussions with health service providers centred on their perceptions of and attitudes towards the current health care services provided to survivors of violence. Exploration was carried out around the following thematic areas:

Knowledge/understanding of IPV and its relationship to health

Skills and needs of service providers

The role of health services in IPV prevention, care and support

Health policies, protocols and guidelines towards IPV in health services

Challenges and opportunities for implementing IPV prevention, care and support at the hospital

Collaboration with other sectors

Existing referral systems, how they are rated and their relationships with referral services in-terms of how comfortable they are to refer their clients to such services

Perceptions of the feasibility of screening for IPV and type of screening.

Perceptions of what type of injuries might reflect an underlying problem

Perceptions of options for improving health services response to IPV

Practices in terms of recording: what might be the potential indicators of violence that they might record in a register?

4.8.2.2 Community entry and consent issues for community interviews

FGDs were held in villages or townships which required negotiations for community entry with a wide range of gatekeepers. Introductory letters to access the villages were obtained from the District Commissioner, City of Blantyre officials and Southern Region Police. The Health Surveillance Assistants (HSAs) initiated discussions with community gatekeepers. Community leaders, who have administrative and moral obligations for the people in their respective villages, were also involved and meetings informed them of the purpose and

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design of the study. Chiefs, who knew individual households well, approached participants through their helpers and HSAs about their potential interest to participate in the study. For young people consent was also obtained from parents to allow their adolescent children (aged over 18 or considered mature minors) to participate in the study. This applied for all young people who were still living with their parents at the time when the study was conducted. Consent was obtained directly from each participant, including the young people 75, 387.

4.8.2.3 Topic guide for discussion with general community members

The following areas were addressed: (see appendix 5)

Their understanding and perceptions of different types of violence that might be experienced within the family/relationships (with a focus on their understanding of IPV) and the potential causes of these

Their understanding of the relationship between IPV and health (e.g. health consequences)

Their perceptions of help seeking and sources of support for people experiencing IPV

Their perceptions of challenges and barriers to seeking and receiving help

Their perceptions of health services for people experiencing IPV and the quality and utility of these

Their perceptions of referral services for people experiencing IPV

Their perceptions of how existing health and other support services could be improved

4.8.3 Semi structured individual interviews with health care workers (IIs)

To maximise opportunities for presentation in areas where FGDs could not be held due to staff shortages and other constraints (see section 4.6.2) additional IIs were conducted with health care providers (see annex 3). These one on one interviews were carried out to uncover individual perceptions, experiences and practice. Either the researcher and/or one research assistant conducted the interviews 388.

One member of staff from each department (where possible) who had not taken part in the focus group discussions was invited to participate in the individual interview (II). Using IIs helped to triangulate the findings from the FGDs. Individual interviews allow the interviewer

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to deeply explore the respondent’s feelings and perspectives on a subject. The confidential atmosphere in which informants can share sensitive information provide for the opportunity to gather detailed information about their personal experiences, opinions, feelings and experiences without the influence of peers 389. The IIs revealed different information from the FGDs despite an almost identical topic guide. For example there was reference to personal experiences, to friends and family members and more freely expressed opinions.

4.8.4 In-depth individual interviews with service users ‘survivors’ (IDIs)

The critical incident technique was used for these IDIs. Critical incidences concentrate on asking the respondent about a key event in their past (in this case help seeking for intimate partner violence) to describe in detail their actions in response to the event or episode including all forms of help used or sought 390. The following areas were addressed (see annex 4):

IPV: Interviewees were asked about what their understanding of what was happening to them, what they think might be the cause and what are the consequences of this.

Help-seeking behaviours: Interviewees were asked whether they sought help following abuse. What made them seek care? Where did they seek help? How satisfied were they with the help they received? If they sought help from the health care workers: which specific services, where did they present first, who were informed? How was disclosure done, how did they perceive the care they received? What made it more satisfying? What made it worse? What was the attitude of the health care providers? What would encourage them to disclose abuse to health care providers? What would make it difficult? How did they cope? What were their experiences of being referred to other services? What was the impact of care seeking on their situation?

What can be done: interviewees were also asked what the health care services can do to improve their response to intimate partner violence, and what priority interventions should the health care providers engage in to prevent intimate partner violence.