Descripció de la població estudiada i de les variables registrades

Ensuring that the participants in the study take part voluntarily is an essential aspect in ethics, therefore the most important aspect of this is ensuring that adequate

information is given to the participants concerning the study, participants are given time to decide on whether to participate or not to, and to ask questions concerning the study. The University of Salford research ethic guidance suggests that participants should be given a minimum of 24 hours to make a decision on whether to participate. However, it is not always practical to do so, as prospective participants might be lost within the 24 hours decision period due to other commitments. However, the duration that would be suitable in each study would depend on the sensitivity of the topic the study aims to explore. That is, in a less sensitive study, that presents little or no harm to the participants the duration for decision-making might be shorter than studies that

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might be more sensitive or harmful to participants. Therefore, due to the less sensitive nature of this study, a short duration was allotted for participants to make an informed decision on whether to participate in the study. Also, putting into consideration that most of the participants the researcher approached at the religious gathering might not be available to meet at a later date because of other commitments or cost of travel, the focus groups and interviews were conducted an hour after participants information forms were given to them.

Gatekeepers are individuals that the researcher uses to gain access to the participants for the purpose of the study (Miller et al., 2012). From an ethical perspective, the researcher has to continually reflect on the influence of these individuals over the study participants. This is very important as they could be seen as coercing participants to participate in the study because of the power they have over this group. Indeed this was a potential problem that occurred during the data collection process of this study as women were seen to be influenced by the religious leaders who appeared to have higher socio-economic status compared to the other women, as many women showed interest in participating in the study. It appeared that it was difficult for them to indicate that they do not want to participate, and this might also lead to the

participants not being able to discuss personal experiences that they feel it might be religiously unacceptable to these gate keepers. Therefore, a decision was made to avoid recruiting participants from the religious gathering; women were then recruited from social gathering. According to Richards and Schwartz (2002), it is the

responsibility of the researcher to reflect continually on how the route with which participants are selected and the motive around participants' decision to participate or not in the research might affect the data collected.

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4.4.3. Informed consent

Written informed consent should be the minimum requirement for health studies researchers because of our duty of care to the participants, and it protects both the participants and the researcher from arguments regarding exploitation (Peter, 2015). However, some researchers believe that this might not be relevant in the qualitative research approach as it might scare participants away from participating in the study especially when sensitive issues are being addressed, as the participants might believe this may be used to breach their anonymity in the study (Richards & Schwartz, 2002). For example a study that aimed to explore the sexual behaviour of young adults in a community might find it difficult to recruit participants into their study as providing written consent might scare participants off the study. Felix et al. (2015) conducted a randomized controlled trial that evaluated the impact of obtaining informed consent from participants on a sensitive health behaviour that participants are requested to report on. They found out that there was no relationship between the completion of informed consent form and self-reporting behaviour with regards to alcohol use. However, the mean age of the participants in the study was 23 years and there is the possibility that the outcome of the study might be different if they had recruited older participants as they were more likely to be embarrassed by them being identified with their alcohol use because they might have some sense of responsibility. However, this is not a major challenge in this study, as it aimed to explore the reasons why women chose to or not to participate in the Lagos state mammography screening programme by discussing these issues in focus groups.

Informed consent should be gained after the participants have been informed about the purpose and scope of the study, types of the questions that would be asked during

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the interview, the ways the result would be used, the method of anonymity, and the extent with which participants would be involved in the study- discuss whether they will be involved in the analysis (appendix E- the consent forms used in this study ). However, because of the flexible nature of qualitative research study the aims of the research is guided by the information provided by the participants and this leads to the argument on what exactly do participants consent to at the beginning of a study?

Knapp et al. (2011) stated that the use of a tested participant information form on potential trial participants in a pilot study might help improve the validity of consent obtained from study participants, as concerns arise over the fitness of these consent form for purpose. Another study (Antoniou et al., 2011) employed another approach to evaluate the amount of information that would be considered as appropriate information on a study by providing its participants with three different amounts of information on the research topic. They found out that most of the participants found the participant information form with the least information more beneficial than the other ones (Antoniou et al., 2011). With the researchers not being able to the know the exact course of qualitative study at the beginning of the study, it might be useful to

consider updating their study’s participant information form as the study progresses if changes are noticed in the data provided by the participants. According to Orb et al. (2001), completing an ethics form at the beginning of a study or obtaining ethics approval does not mean that ethical issues can be forgotten. However, ethics should be ongoing in qualitative health research and as studies progress there is the need for the researcher to regularly reflect on the process of the data collection as this might improve the ethical and methodological strength of the study. However, this might not be practical in most qualitative research studies where data analysis is conducted after

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the data collection. Therefore, because of the short time frame allotted to data collection in this study (6 months), the researcher had to analyse the data collected from the participants after the whole data collection process. This does not offer the participants any chance of knowing how their views have affected the research aim. However, the author’s intention of providing necessary information concerning the

study on a blog for the participants to read after the study can help eliminate this limitation.

4.4.4. Confidentiality

Confidentiality is the process of safely keeping the information provided by the

participants from people that should not have access to them (Long, 2007). Therefore, it is the responsibility of the researcher to inform the participants of whom the

information they give at the interview or focus group discussion would be revealed to and to what extent would the information be used for in the study. A study that cannot address this issue might lead to the participants not being willing to participate in the study or participants not willing to give an in-depth explanation of their views on the topic. In the study’s participants information form, and the interview and focus

group discussion guide, the author explained how the information provided would be used and explained to the participants that the interview and focus group discussion transcripts were uploaded in a secure internet account because it is safer than having to save it in a secure data storage unit as it could be stolen (Holloway & Wheeler, 2013). The data was shared with the researcher’s supervisors as they used it to ensure that the methodological and ethical considerations are continually reassessed during the course of the study.

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Furthermore, to ensure that what was discussed in the focus groups was not shared with anyone outside the group was essential as participants might not see it as a problem and vital or personal information shared within the group might be discussed with other people outside the group. This could cause embarrassment and distress to the participants who had given the information. However, it was indicated on the focus group consent form that participants should not discuss any information shared in the group discussion outside the meeting. Therefore, this might have encouraged the women to discuss their views on the topic without being afraid of who might be listening.

4.4.5. Anonymity

Anonymity is the process of concealing the participants’ identity. This process is a

means of reducing or avoiding a potential risk that qualitative research approach presents which is the identification of participants in published paper by themselves or others (Richards & Schwartz, 2002). However, this is a challenge with the study’s

interview participants as they were mammography practitioners and there were very few of them. Therefore, there is a possibility of the participants using elimination

method to identify other participants’ views on the topic. To overcome this challenge, the researcher intends to readjust the consent form stating that it might be possible for other participants to know what their views are because of the small size of the interview group. In addition, a copy of their views that would be in the publication would be shared with them and their consent would be gained before they are published. Finally, in a case where their views might affect their role as a

mammography practitioner or their relationship with other members of staff; these views would be shared with them and they would be asked if they would like this to be

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in the published work. However, this challenge is not significant in the focus groups as there were many participants in the groups, and seven different focus groups were conducted at different places.

Finally, in both the interview and the focus group transcripts, participants would be

represented with pseudonyms (for example, ‘participant 1, 2, 3 etc.’), and the focus

groups would be represented as ‘Focus group 1,2,3 etc.’ , to avoid them being

identified by other people (Holloway & Wheeler, 2013).

4.4.6. Risk management

Due to the flexible nature of the qualitative research approach, the interviewers are allowed to ask probing questions to gain in-depth understanding of what the

participants reveal during the interview and focus group discussion (Miller et al., 2012). However, during the interview or focus group discussion the participants might ask unforeseen questions, to have a better understanding of the question and its context, as they could be anxious or depressed because of the information that they have heard before or during the group discussion (Peter, 2015). To overcome this challenge in the study, an experienced mammography practitioner volunteered to discuss about the mammography-screening programme and answer questions related to the

screening programme after the focus group discussions, as she had already been giving talks at non-governmental organisation seminars organised for women on

mammography screening programme. In the case where the mammography

practitioner could not address the questions asked, the women were referred to their doctors for further clarification. Doing this helped minimise the risk of harm; it also help educated these women on mammography screening and breast cancer- a benefit of participating in the research.

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Theft of data collection instruments whilst on the research field could lead to the researcher losing the data collected. Losing the data collection instruments might cost money and time to collect the data from the participants again. Furthermore,

participants too might feel that they are being harassed if the researcher contacts them for a re-interview (Richards & Schwartz, 2002). Therefore, the use of Google dropbox to save audio data collected from the interviews and focus group discussion, and insuring all the electronic devices such as laptop, mobile phone and digital audio recorder, so that they can be replaced in the events where they are stolen or

damaged.

4.5. Research design

“Qualitative inquiry is inductive, that is, it goes from specific and unique cases to general and hence develops theory or theories” (Holloway & Wheeler, 2013) p. 11. In qualitative research approaches, theories are developed from the data collected as opposed to the deductive nature of quantitative approach, where a hypothesis is developed from the beginning of the research and then tested (Green & Thorogood, 2014). However, the absence of hypothesis at the beginning of the research does not mean that existing theories are not used at all during the research. The prevailing theories and related literature helps in identifying certain outcomes in the data that may have been missed (Painter et al., 2008). However, some qualitative researchers argue that this is not always the case as the initial knowledge of existing theories and

related published evidence may inform the researcher’s position and introduce bias in the data collection process and analysis.

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As the participants are given a voice through qualitative research, this approach aims

to reduce the biased outcomes that can result from interpreting the women’s views.

However, a novice researcher in qualitative health research can get overwhelmed by the richness of data generated from participants and miss some important

information. Therefore, the use of theory and background knowledge is an acceptable approach to guide the study. In the current study, the theory of care seeking behaviour is, hence, utilised as a framework on which to build the project.

Data collection began in September 2014 and it is completed. The initial phase of data collection concentrated on developing knowledge of the existing theories and

published evidence on the topic (see in figure 4.6.). The theory of care seeking

behaviour (TCSB) was considered at several points in the research process- developing interview and focus group guide; data analysis; and dissemination of findings . The process of understanding the body of evidence was used to guide the analysis and presentation of the data collected. Furthermore, the main data collection from the participants, evolved through three interrelated phases. The first phase was a pilot focus group discussion with Nigerian women currently living in the United Kingdom. This was conducted with preconceived ideas as focus group questions are guided by the theory of care seeking behaviour. This focus group discussion develops the skills for conducting a focus group meeting (Silverman, 2013). It also helps explore women’s

understanding of the questions and the appropriateness of the order of the questions (Barbour, 2007). Following ethical approval, a convenience sampling of participants was used to recruit participants into the focus group discussion. A semi structured guide was utilised; the conversations are audio recorded and the transcript is made verbatim. The focus group discussion guide is further redefined with the information

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generated from the participants (this is discussed in detail in chapter nine through a process of reflection).

Figure 4. 6 The Research Process.

The research then focusses on the opinion of mammography screening staff, as it significantly impacts the patient experience and provides a more holistic view and aesthetic understanding of the topic. The purposive sampling method is used to recruit four mammography practitioners and a radiologist for interview at the Lagos State University Teaching Hospital and Lagos State General Hospital. The researcher used a semi-structured guide and the conversation was recorded on a digital audio recorder

Gathering evidence related to the topic Develop research questions and interview guide- TCSB Pilot focus group discussion with a similar sample Interview with mammography practitioners Focus group discussion with women in Lagos state Data transcription Initail data analysis using the indirect content apporach Secondary analysis guided by the TCSB Dissemination of findings- TCSB

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(see interview data in chapter five). This leads to the final phase, where women were initially recruited from religious gatherings by using purposive sampling method. However, later on they were recruited from social gatherings by method of

snowballing because the former method proved challenging for the data collection process (explored in chapter nine). Seven focus group discussions were conducted with 8- 11 women in each group, and the average time spent at the meetings was 46

minutes (see focus group data in chapter six). The researcher is a diagnostic

radiographer and was the moderator for these focus group meetings. A mammography practitioner who had previously been involved in educating women about

mammography screening programmes, volunteered to be the note taker at the

meetings. The justification for the use of different elements in the research design has been discussed in the previous section of this chapter.

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Chapter 5: Interview Data