Thematic analysis, as developed by Braun and Clarke (2006; 2013) was used to analyse the data. Data analysis commenced at the beginning of the study during observation and informal conversations with healthcare providers and was ongoing throughout. Hammersley and Atkinson (2007) note the importance of the process of familiarisation with the data. Personally transcribing interviews, hearing them multiple times ensured I became familiar with the data as I had time to reflect on ideas and time to listen to the intonation, emotion, and silence of the interviewees. I was surprised at the many details that I had not noticed at the time of interview: the emphasis, intensity and even humour of participants.
After transcription I coded the data section by section often using ‘in vivo’ codes (Holloway and Wheeler 2010) such as ‘no-one appreciated us,’ and ‘we can easily be replaced.’ Similar codes were grouped into a category such as ‘not being valued.’ Transcripts were re-read as patterns and relationships emerged
and categories developed. Selected interviews were read and coded by two of my supervisors. For example ‘not being valued’ was linked with the category of ‘no powerful connections’ and became the more conceptual category of
‘vulnerability’. Categories were checked against the data and redefined where a more appropriate concept was identified (Forrest Keenan et al. 2005; Clarke and Braun 2013). The initial category ‘powerlessness’ was renamed
‘vulnerability’ as I realised that all healthcare providers had a degree of power over women having their babies and their relatives by nature of their insider knowledge but some were also vulnerable within the wider hospital hierarchy. This was an iterative or “recursive process” as I reflected on the data and at the same time collected more (Braun and Clarke 2006; Srivastava and Hopwood 2009).
I started analysis with pen and paper, printing out all interviews, cutting them up and grouping categories together in folders. After my first eight background interviews I realised that this approach was not going to be practical, that there was too much data. I continued to print and mark all the transcripts by hand but then computerised the categories by creating documents and folders including many ‘in vivo codes’. I considered using a qualitative analysis programme, however, after discussion with my supervisors it was decided that it would take too long to learn the programme and that it would be simpler to analyse without.
This study used several methods and included diverse groups of participants. To achieve a systematic analysis that also maintained the contexts, methods and perspectives of individual groups, two strategies were employed. First, participants from the hospital interviews and background interviews were grouped in each data set according to profession and seniority, Afghan or non- Afghan healthcare professional, Afghan non-health professionals or
representatives from the Ministry of Public Health. This ensured that issues of importance for the various groups could be identified. Secondly, each data set was analysed separately prior to analysing across the data (Braun and Clarke 2006). Data, therefore, from my observations, the community focus group discussions, background interviews, informal group discussions and the
hospital healthcare providers’ interviews were analysed as discrete data sets. The categories from each data set were then compared and refined using a broad framework. The themes from all the data sets were amalgamated into the final overarching themes.
Tsai et al. (2004, p.10) stress the importance of including those who understand the culture and language of the participants in the data analysis process in endeavouring to produce “culturally competent health knowledge”. As themes have developed I have continued discussions with two linguistic and cultural experts to ensure that these resonate with wider Afghan values and culture.
Five themes were identified in this study: The culture of care; staff motivation; fear, power and vulnerability; challenges of care; family and social influences on care. There is too much information to be discussed within the confines of this thesis, and therefore I have focused on three themes that encapsulate the most unusual and pertinent areas in answering the research question as a maternal health researcher: the culture of care; challenges of care; and fear, power and vulnerability. It was not possible to discuss every facet of the individual themes as they encompass most aspects of this institution. The more uncommon
aspects have been selected and the ones that relate most directly to the care of women. Many factors that motivated and demotivated the healthcare providers were identified. Some of these factors will be mentioned, however, I decided that to examine motivation in detail would be to divert from the central focus of the culture of care. I originally thought that I would explore the influence of family and Afghan society on hospital care in detail. Reflecting on the data I realised that whilst the impact of family obligations on the behaviour of staff is of interest to those from more individualistic societies, the healthcare providers themselves mostly chose to talk about other issues. The foundational (core) value of family as an underlying driving force must be included as it indirectly and directly affects most aspects of this hospital culture. It will, therefore, be a thread that runs through the findings rather than a separate chapter. Fear, power and vulnerability profoundly affected work and relationships in the hospital. This theme was separated into two chapters. The first, the climate of
fear, focuses on the healthcare workers’ experiences of fear and horizontal violence. The second, the final discussion chapter, develops the analysis of power and power struggles as the underlying driver for the fear, hostility and fractured relationships within the hospital. Finally, the discussion chapter returns to care and the implications of the analysis for improving care.