Understanding delayed access to antenatal care: a qualitative study Rosalind Haddrill

3.1.3 The main features of the methodology

The essential features of the qualitative methodology are considered below and are explored in terms of the general conduct of the research. A more detailed consideration of influences on the study methods, including sampling, data collection and analysis, is presented in section 3.2.

3.1.3.1 Focus on the emic perspective

The research takes an emic perspective as its starting point, focusing on ‘the inside view’: the differing views of the people involved in the research rather than those of the researchers themselves. The aim has been not to adjudicate between accounts, but to uncover meaning and to understand how people interpret their experiences and behaviour, and the rules that govern their actions. There are two central tenets to the approach: face to face interaction and adopting an empathetic stance (Lofland et al 2006, Green and Thorogood 2014). The latter requires an empathetic understanding (reflecting Weber’s verstehen) of meaning, behaviour and intentions and a recognition that participants have a voice, which is there to be discovered, rather than imposing the researcher’s perspective and any prior assumptions they may have. Quantitative research has been accused of ‘riding roughshod’ over participants’ meanings, and of taken-for-granted assumptions distorting findings (Murphy et al 1998).
The study’s flexible methods, from sampling to data collection and analysis, reflect the desire to hear women’s ‘voices’ on late booking. They were developed in order to enable women to speak openly and at length about their experiences of becoming pregnant, about delays in seeking care, and their knowledge of antenatal care, and the influences on these, without superimposing preconceived ideas. They were also created to examine their perceptions and beliefs during pregnancy and how these impacted on their behaviour.
The emic approach also recognises that individuals are the experts of their own lives, both in terms of feelings and experiences, and that people make their own definitions of reality and normality which could be dynamic or changing. In health research this empathy is acknowledged as an essential part of changing behaviour, for example in terms of successful health promotion and education activities (Green and Thorogood 2014). A successful relationship between researcher and researched is thus close and equal, non-judgemental and honest, with participants having control over the research process. The researcher’s view (the etic perspective) emerges during the subsequent analysis and reflection process, with the researcher moving backwards and forwards between the two views (Holloway and Wheeler 2010).

3.1.3.2 Data has primacy

The research has attempted to produce rich, in depth, textual data, allowing for the description and interpretation of participants’ experiences; detailed portrayals of the processes underpinning social activity: context, behaviours and beliefs (Green and Thorogood 2014). This necessitated probing beyond the surface appearances often captured in quantitative approaches. As Denzin (1989) describes it: “Deep, dense, detailed accounts… detail, context, emotion and the webs of social relationship” (p83). This use of ‘thick description’ (as expressed by Geertz 1973) enables researchers to go beyond the constructions of the participants, moving to a more abstract and theoretical level to generate new theories rather than testing existing ones. This reflects not simply a direct reproduction of the findings but an inductive process of selection and interpretation, of imbuing descriptions with theoretical assumptions; a process where the data has priority (Murphy et al 1998, Holloway and Wheeler 2010). This focus allows ‘the broader context of social behaviours to be delineated’ (Green and Thorogood 2014: 26), a merging of participants’ lived experiences and interpretation of those experiences (Ponterotto 2006).

This focus on creating something which is not merely observational, but also theoretical and analytical, and which ultimately has a purpose, is important. Denzin (1971) comments that social research should reproduce, in a rich and detailed fashion, the experiences, thoughts and languages of those studied, in an attempt to impose order on the social world. The study’s aim was to capture the depth and detail of women’s experiences, using these stories to interpret women’s experiences more broadly, constructing new theories about why women present late for antenatal care. This reflects pragmatic considerations in a process which aimed ultimately to influence future practice through the development of ideas and interventions which could be tested on a larger scale. This in turn reflects Medical Research Council (MRC) guidelines for the development of such complex interventions, which identifies key elements of the systematic development process, including

1. 
   Identifying the existing evidence base through a systematic review of the literature; and
   
2. 
   Identifying and developing theory, supplementing existing evidence and theory with new primary research, for example interviews with ‘stakeholders’ (MRC 2008: 9).
   

3.1.3.3 Context is important

The research methods have demonstrated a commitment to a holistic understanding of social behaviour through naturalism - studying people in context, in ‘natural’ or ‘real life’ environments. This is in contrast to the controlled, experimental or artificial conditions aspired to by many quantitative techniques. This allows the researcher a view of the ‘real’ world of participants, an opportunity to see their point of view and how they construct situations. There is an acknowledgement of the need for sensitivity, to study people on their own terms and to respect context and culture. There is also a recognition however that true naturalism is somewhat idealistic, as the act of observation itself will impact on that being observed, and that what is produced is a ‘situated account’ (Murphy et al 1998). However, there is also a commitment to reflexivity and reflecting how the research setting has in itself had an impact on behaviour (Pope and Mays 2006, Holloway and Wheeler 2010, Green and Thorogood 2014). Data collection methods reflect the consideration of context, ‘natural’ settings and relationships, from both home and work. These recognise what is essentially an artificial encounter, whilst aiming to promote openness and honesty, and giving participants some ownership of the study. This context has the potential to influence the content and depth of the data collected.

3.1.3.4 Reflexivity and critical thinking are essential

Research is not value free, and investigators cannot be divorced from the cultural, social and political context of their topics; and because researcher and researched are part of same world, there can be no truly objective viewpoint (Bowling 2009). Reflexivity in qualitative research acknowledges this awareness of the impossibility of remaining outside of one's subject matter throughout the research process, and the researcher's potential contribution to the construction of meanings (Nightingale and Cromby 1999). This recognises the constructivist view, acknowledged by Bryman (2008) who considers the role of the researcher as ‘part and parcel’ of the construction of knowledge. The values of a researcher can influence and inform every aspect of research, therefore it is essential for researchers to be self-reflective and exhibit reflexivity about the part such influence plays, considering how their own actions, values and experiences impact on the research setting, data collection and analysis (Gerrish and Lacey 2006, Bryman 2008). This is the opposite to the impartiality and objectivity of many quantitative traditions, with their goal of avoiding ‘bias’. Qualitative research is not simply subjective story telling: reflexivity is one of the ways qualitative researchers take subjectivity seriously and can validate their research practices; part of any strategy to maximise rigour and credibility. It is a continuous and integral process (Lambert, Jomeen and McSherry 2010, Green and Thorogood 2014).

It can be argued that researchers should approach reflexivity in two ways. Firstly, more strategically, they should reflect critically on the research itself, considering the broader political and social context of the research. This will help to unpack any assumptions that they have brought to the research, and to identify the ways in which this context might shape what they find, for example assumptions about what is correct behaviour. This might incorporate scepticism or rejection of received wisdom, of normative assumptions built into many research studies, for example the perception of ‘barriers’ or the value of an activity, in this study early access to antenatal care. Willig (2001) argues that there should also be an element of ‘epistemological reflexivity’, which encourages us to reflect upon assumptions we have made in the course of the research, and think about the implications of such assumptions for the research and its findings.

Secondly, more personally, there should be a consideration of the researcher’s role in data ‘production’ and analysis: who you are will shape findings. As Kuhn (1970) identifies, what we see depends on what we look at and what our previous experiences have taught us to see. This could be considered as helping us to ‘situate ourselves’ in relation to the data. There needs to be a critical reflection on what has been thought and done, an explicit self-awareness of the researcher and an awareness of the interaction between researcher, researched and the research itself (Holloway and Wheeler 2010, Green and Thorogood (2014). Lambert, Jomeen and McSherry (2010) argue that this reflexive engagement forms part of a positive process of knowledge acquisition, transfer and validation which can be applied to future practice, again reflecting the study’s pragmatic aims. Further consideration of reflexivity in relation to the study methods is presented in section 3.3.2.

3.1.3.5 A flexible research strategy

The research has used flexible and dynamic strategies which have adapted as the data has been produced and analysed, with an emphasis on capturing the process as much as producing the final ‘product’ (Bryman 2008). This is in contrast to the ‘input-output’ model characteristic of much quantitative research and is well suited to theory generation and discovery (Murphy et al 1998). In this emergent approach, stages have overlapped and informed each other, for example refining the research question or adding to the sample to give depth, a common approach in grounded theory research. Different methods have been used, reflecting the notion of the ‘bricoleur’ (someone who makes something from whatever materials are available) adapting and devising methods of inquiry for changing perspectives, emerging findings or utilising unexpected opportunities for data collection (Green and Thorogood 2014). This flexibility, adaptation and overlap were evident, in fact highly necessary, throughout the study, at different levels. Recruitment challenges and discoveries amongst initial data collection informed sampling methods. Also methods were modified during the study to facilitate more open discussions and achieve a greater depth and diversity of perspectives.
3.2 Determining the research methods

“the problem under investigation properly dictates the methods of investigation”

(Trow 1957 cited in Bryman 2008: 468)

The research methods developed in response to the features of the qualitative methodology and the ontological and epistemological principles which underpin it, in turn reflecting the study’s aims and the research question. They represent the balance of theoretical, ethical and practical influences and decisions made prior to and during the research process.