La casa grande de los mojeños: el territorio

All qualitative investigations focused around key themes and sentences that were structured in a topic guide used to conduct discussions and interviews, while simultaneously favouring participants to elicit broader responses, particularly stories, emotions, contrasting opinions and conflicts.

Investigations sought to explore and cast new light on factors and dynamics that could impact positively and negatively on CHWs’ performance and its potential effectiveness in their routine work, as well as a consequence of the intervention, with a focus for maternal and child health.

The assumption behind the definition of core themes and sentences was that CHWs’ performance is subjected to the influence of two major contextual determinants: the formal health system and the community system (Schneider et al., 2016). These concepts are backed up by international literature on CHWs performance and Brazilian national documents that define details and activities of CHWs programme (Chapter I; MoH, 2012; Glenton et al., 2013; Naimoli et al., 2014; Kok et al., 2014; Kok et al., 2015; Schneider et al., 2016).

Key sentences were: “barriers and facilitators (factors and dynamics, internal and

external to health units) to quality improvement of CHWs’ daily activities”, “barriers and facilitators (factors and dynamics, internal and external to health units) that impact on CHWs’ performance”, “barriers and facilitators (factors and dynamics, internal and external to health units) that shape and impact CHWs and team relationships”, “barriers and facilitators (factors and dynamics, internal and external to health units) that shape and impact CHWs and community relationship”, “barriers and facilitators (factors and dynamics, internal and external to health units) that shape and impact CHWs’ preparation, organization and practice, especially for home visits”, “barriers and facilitators (factors and dynamics, internal and external to health units) that shape and impact CHWs’ preparation, organization and practice, especially for maternal and child health”, “positive and negative factors, dynamics and consequences of the training and guide delivered as part of the trail intervention on CHWs”, “positive and negative factors, dynamics and consequences of the training and guide delivered as part of the trial intervention on team work”, “positive and negative factors, dynamics and consequences of the training and guide delivered as part of the trail intervention on the relationship CHWs-patients”.

The topic guide served the researcher to standardize data collection and manage communication needs and barriers across different groups of informants in order to grant mutual understanding and successful sessions. For these reasons, the content and jargon of the guide were pilot tested with a group of CHWs, nurses and doctors that were not involved in the trial, but similarly employed in the primary health care sector, and modified accordingly.

The guide was divided into three major blocks: an introductory one, with the presentation of the objectives, methods and participants of the research, including the profile and role of the researcher; a central one, with core elements of the investigation

and the list of themes and sentences coupled with notes derived from the pilot testing on how to frame the same question to a different audience; and a closing one, with conclusive remarks on the research process and future steps deemed to be recalled to research participants.

The guide was conceived as a semi-structured tool for balancing the researcher’s needs and perspective , which require standardization, and the unique, but diversified, views of participants, which require flexibility (Merriam, 2014). On one side, standardization, reached by having granting a predetermined set of topics across all data collection sessions, allowed for comparisons across perspectives of different groups of individuals and professions in relation to similar experiences. On the other side, the flexible use of key sentences, their order and their wording, favoured the adaptation of the researcher to the context and the better exploration of emerging worldview and ideas of the respondents (Merriam, 2014). Audio recording was available during all sessions to consent the researcher to add further notes on the responses and their transcripts, including non-verbal behaviours and the general climate.

2.4.3.1 Focus groups discussions with CHWs

All CHWs who participated in the project, as part of the intervention or the control group, were invited to participate to focus groups.

Focus group discussions were found to be the most appropriate method for exploring views, experiences and opinions of CHWs on the research subject, namely CHWs’ challenges and opportunities in relation to their performance and routines (before and after the intervention), within their complex and dynamic environment and network. Being centred on a defined collective phenomenon and identity, focus groups were thought to facilitate, more than individual interviews, comparison of different perspectives about the same social practice and context, to enhance chances of critical reflection about issues affecting everyday’s life of CHWs, which are not normally discussed, and to access information on topics, such as relationships with members of the team and the community, that would have been probably difficult to disclose to strangers with individual discussions (Creswell, 2013; Creswell, 2014; Patton, 2002).

A total of 73 CHWs representing all 12 FHTs attended focus group sessions. Out of the total of CHWs involved in the trial, only 5 were missing from the control group, while all 31 CHWs belonging to the intervention group participated in the discussion.

Focus groups were organized outside the health units, in a neutral space, to allow CHWs to freely express opinions related to their work with other health professionals working with them in team, and their communities.

Discussions were held in six sessions of 2 hours approximately. Three were hosting from 10 to 11 CHWs belonging to the intervention group, and other three from 13 to 15 CHWs of the control group. Within each group, CHWs were selected to differentiate their origins, here defined by their affiliation to FHTs and Districts. This criteria maximized the variation of participants within each group, in order to assure that discussion amongst CHWs could benefit by the intervention of peers employed in different units, rather than colleagues who share daily the same challenges and opportunities (Table 20).

Table 20 Composition of the focus groups discussions

Group _numberSession Total of_{CHWs represented per group}Total number of FHTs _{Districts represented}Total number of Intervention 1 10 3 2 2 10 3 2 3 11 3 3 Control 12 1315 54 33 3 14 6 3

During the sessions, each participant was assigned with an ID number by the researcher who drew a map of them to facilitate the record of their contributions and to match them with the focus groups transcripts afterwards.

The number of sessions had to balance the needs for in depth investigations into CHWs’ views and experiences with logistical and financial constraints. To secure the attendance of CHWs, District managers and coordinating nurses of each family health team had to approve the activity, while transport and food for all CHWs had to be organized and granted.

Although the number of sessions was limited by external constraints, the saturation of themes and contents was reached within the reports of the intervention and the control groups; therefore, the number was a considered sufficient to fit the purpose. Additionally, the freedom of expression and dialogue exhibited by participants during focus groups, as well as the depth and breadth of their discussions, decreased the chance to get new insights on the research themes through in depth interviews with CHWs, or a sub-set of them.

2.4.3.2 Semi-structured interviews with nurses and doctors

A total of 19 semi-structured interviews were held with 11 nurses and 8 doctors, representing a total of 11 FHTs for all three districts. Only one nurse of the intervention group was not reached, while all three doctors who took part to the training accepted the invitation for taking part in the discussion.

Interviews were preferred to other type of data collection methods since they are thought to be the best choice for conducting intensive case-studies on few selected individuals (Patton, 2002; Merriam, 2014). Moreover, interviews were held separately with each individual in order to facilitate the exploration of team dynamics, including sensitive issues, such as the relationship between health professionals belonging to different professional categories, which would have been difficult to capture otherwise. Collective methods of discussion, such as focus groups, would have challenged the possibility to freely express experiences and opinions regarding colleagues and team members (Patton, 2002; Merriam 2014).

As previously mentioned, the semi-structured format of the interviews permitted to explore a standardized set of themes by the interviewer, but at the same time allowed for new insights and ideas that could be further investigated and that could emerge through the interviewee words (Creswell, 2013; Creswell, 2014; Patton, 2002).

To grant participation and privacy of respondents, the location of all interviews also varied accordingly to interviewees needs and data protection.