Introduction
The previous chapters discussed the contemporary relevance of religiosity and self-care among Indonesian Muslims with type 2 diabetes. This chapter focuses on how the researcher conducted the study. It begins with a discussion of the philosophical paradigm that underlies the research, highlighting the researcher’s epistemological and ontological positions and the paradigm shift that took place throughout the course of the research process. The chapter focuses on the methodology underpinning the research and the methods used to collect and analyse data. The issues surrounding translation of interview transcripts are also discussed. The chapter concludes with a discussion of reflexivity, or how the researcher sees himself in the process of data collection in order to be transparent and to ensure the quality of the research (Gray, 2014).
Philosophical Paradigm
This first section will explore the ontological and epistemological perspectives that underpin the research. It is necessary to consider such philosophical positions since it will help the researcher to answer the question of ‘why (and how) conduct research?’ (Remenyi et al., 1998); to develop understanding of the nature of reality; and to guide understanding of how that ‘reality’ becomes knowable (Saunders et al., 2009). Or, to put it another way, ‘whatever methods or procedures give us knowledge of what there is must depend, in part, upon what there is to be known about’ (Hughes & Sharrock, 1997). However, it is not the researcher’s intention to conduct a theoretical exploration of philosophical paradigms, rather, as an effort to reflect upon the epistemology of choice and to able to defend it among the alternatives (Saunders et al., 2009).
It has been suggested that how human beings understand the nature of reality can be placed on a continuum between two poles of objectivity and subjectivity (Holden & Lynch, 2004), or positivism and interpretivism (Hughes & Sharrock, 1997). Thus, in the effort of how to gain knowledge and understand the phenomenon under study, objectivists are inclined to follow a
89 systematic and measurable method (Creswell, 2014), whereas subjectivists tend to explore the subjective meanings of experiences.
Objectivism
At one end of the philosophical spectrum is objectivism which believes that reality and meaning exist apart from our consciousness and the researcher tries to discover and observe it (Crotty, 1998; Avramidis & Smith, 1999; Holden & Lynch, 2004). Thus, objectivists believe that empirical evidence is essential in order to gain knowledge of the phenomenon under study, reducing it into fixed, tangible and permanent matter (Hughes & Sharrock, 1997). In regard to human science, however, this view poses a dilemma and has triggered debate among social scientists in ‘overcoming the distinction between “things material and things human”’ (Hughes & Sharrock, 1997, p. 29). To put into perspective, subjectivists challenge how an understanding of beliefs, emotion, morality, and the like can be gained the same way as understanding of the sun, the anatomy of the body, or plants, and so on so forth, which is a very different issue.
Subjectivism/Interpretivism
In subjectivism/interpretivism, temporal, cultural and social factors are involved in generating knowledge, and, as Temple (2006) argues, there is no single objective reality, rather different perspectives that create different meanings and understandings. To put the matter into the context of this research, Javanese culture has its own perceptions of hardship, fate and the world as a whole and these are congruent with Islamic values.
Based on the belief that there is no single reality waiting to be discovered but instead reality is socially constructed, the researcher in this paradigm endeavours to discover individuals’ perspectives of phenomena and the context in which these occur. As Saunders et al. (2009) argue, each human being is a ‘social actor’ (p.116) and social actors are influenced by context, temporality and culture. This notion is relevant to this research in relation to social ties and norms in Javanese culture: Javanese people regard keeping harmony with others as an ultimate philosophy of life (Koentjaraningrat, 1985). Therefore, considering the complexity of human beings, interpretivists believe that in order to gain knowledge and understand about phenomena,
90 a subjective approach is appropriate. Within the interpretivist paradigm, a qualitative methodology is often used.
Methodology: The Value of Mixed Methods
A mixed methods approach uses a combination of qualitative and quantitative approaches and data (Creswell, 2014). Mixed research methods in this study are used to complement each other, to ‘maximize the ability to bring different strengths together in the same research project’ (Morgan, 1998, p.362). Mixed method approaches highlight differences and similarities, triangulate data and allow for the development of theory (Morgan, 1998; Sandelowski, 2000; Creswell, 2014). Furthermore, Creswell (2014) argued there are three primary models of employing the methods, those are: converging or merging quantitative and qualitative data in order to provide a comprehensive analysis; using qualitative approach to explain in more detail the results from previously conducted quantitative research; and, the reverse of the second method, which employs a quantitative approach based on a qualitative approach to build an instrument. The approach to this study is discussed in the following section.
The potential benefits of using a mixed methods approach are as follows: first, the integration of these two approaches could add more credibility to a study, a qualitative approach provides more explanation to a quantitative study by adding depth and insight to ‘numbers’ through the inclusion of narrative, dialogues; while a quantitative approach adds precision to ‘words’ through inclusion of numbers and pictures (O’Leary, 2010). Second, a mixed methodology can help the researcher in providing better opportunities to answer the research questions, as well as to gain more trustworthiness and generalizability (Saunders et al., 2009).
Shifting the Paradigm: a Journey to a New Philosophical Stance
This section will discuss the endeavours that the researcher has made in conducting the study. This involves a personal account as well as an academic journey to a new way of thinking. A more detailed account of reflexivity is included at the end of the chapter.
In engaging with the research, the researcher found himself encountering a new perspective of research in term of ontological and epistemological positions. Before commencing the study, the researcher regarded himself as a novice lecturer and researcher with minimal research
91 experience in both objective and subjective terms. As a lecturer, the researcher used to engage in supervising undergraduate students’ work and with his quasi-experimental research experience for his master degree; such experience shaped his inclination to research in an ‘objective’ manner. When the researcher started the study, he still had his own perspective as a Muslim lecturer with a more objective background of research with his own perception of reality. The opportunity to seek further study abroad placed him in the advantageous position of being detached from his origins and also able to engage with other ways of thinking. And as time passed, with the support of his new western environment, the researcher began to build a new understanding of how to approach the study. In other words, being native to Indonesia but accustomed with Western culture and practice gives the researcher a multi-dimensional perspective to examine the issues of how religiosity and/or spirituality, with the interwoven Javanese culture, influence Indonesian Muslims in managing their daily self-care activity. Additionally, throughout the research process the researcher’s epistemological position shifted along the continuum from a traditional positivist stance to an interpretivist one.
Research Methods
This study used a mixed method research design, combining qualitative and quantitative methods, as to ‘maximize the ability to bring different strengths together in the same research project’ (Morgan, 1998, p.362). The Muslim Piety (Hassan, 2007) and the Summary of Diabetes Self-Care Activity (Toobert et al., 2000) questionnaires were used as tools to gain an initial understanding of the diverse and rich sample with respect to levels of religiosity and self-care (Patton, 1990). Therefore, according to Creswell (2014), the study will deploy an explanatory sequential methods approach. It is argued that the uses of a qualitative method will enhance the understanding of how individual perceptions can be gained rather than using a quantitative measure alone (Rogers, 2010); helping in exploring the meaning of constructs and the interrelationships between them (Creswell, 1998). Furthermore, the underpinning aim of the research was to gain an understanding of the experiences and perceptions of people with type 2 diabetes; how they perceive religiosity, within the context of Javanese culture, and apply it to manage their condition in daily life. For this reason exploring patients’ experiences as they were ‘lived’, using semi-structured in-depth interviews is consistent with the study objectives.
92 Population and Sample
The population of the study was Muslim adults with type 2 diabetes from both the Rumah Sakit4 Pembina Kesehatan Umat Muhammadiyah (RS PKUM) and the caretaker of the health of community hospital Muhammadiyah, in Yogyakarta, Indonesia. The hospital is a private hospital owned by Muhammadiyah, the second largest Islamic organization in Indonesia, with a majority of Muslim patients. To establish the study context, further discussion of RS PKUM is now provided.
RS PKUM
RS PKUM, as the official website address is, or PKU as people in Yogyakarta know it (and as it will be used throughout this work), is located in the heart of the city of Yogyakarta, the capital city of Daerah Istimewa Yogyakarta (DIY) or the Special Region of Yogyakarta. It was originally built as a small clinic in the village of Jagang, Notoprajan, Yogyakarta in 15th of February 1923 by H M
Sudjak, with the full support from KH Ahmad Dahlan, the founder of Muhammadiyah ("RS PKU Jogjakarta," 2014). Initially, it was established by the name of Penolong Kesengsaraan Oemoem (PKO) or the saviour of public misery, to deliver a health care service for the poor or dluafa’ in Islamic terms. Although it bears the name of Muhammadiyah, it is not necessarily limited the service only to the community of this social organization.
PKU has been established as a B class hospital, with A considered to be the top level, involving such speciality as Internal Medicine, Paediatrics, Obstetrics, Gynaecology, Surgery and sub- speciality health care services such as a Haemodialysis clinic, Trauma Centre and Orthopaedic clinic ("RS PKU Jogjakarta," 2014). PKU has also been serving as an education hospital for students of the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, the place where the researcher has been working.
Population
The population of the study was type 2 diabetic patients from the out-patients of the Internal Medicine clinic. According to the 2010 database there were 610 cases of diabetes, which were
93 not classified into types. The sample was selected using the following inclusion criteria: Muslim, over 18 years old, male and female, diagnosed with type 2 diabetes for over 12 months, under the care of a consultant and being treated according to the Indonesian Endocrinologist guideline or Perkeni (2011). Patients would be excluded if they were diagnosed and were being treated for a mental health problem, this was to ensure that they were competent to provide consent to be involved in the study.
Sample
The sample for the questionnaire was gained through direct approaches in the waiting room’s clinic. During a three month data collection period it was hoped that a minimum of 100 respondents could be recruited to gain a wider perspective of the self-care activity of the people accessing the clinic. All participants who completed the questionnaires, were given the opportunity to take part in an interview, by indicating their contact details on a reply slip attached to the questionnaires, to be contacted by the researcher at a later date. Prior to each interview participants were contacted and their consent to be involved was confirmed before an interview was scheduled. Written consent was obtained from each participant before each interview commenced. Interviews took place in the preferred location of the participant, which was mainly their own home, except for one participant who chose a waiting room of a hospital where she had been taking care of her husband, and another who preferred her office.
Following the deployment of the questionnaires, the semi-structured interviews were conducted. The sample collection technique for this next phase was known as a quota sampling technique (Saunders et al., 2009), which refers to non-random sampling and a procedure to systematically divide participants based on specific characteristics that are relevant to the research question. According to this technique, participants were to be divided into four categories based on the different level of religiosity and self-care, which are each divided into high levels and low levels. Furthermore, each category would have the same amount of participants based on gender and age groups. Hence, it was expected that each category would have six participants with different genders from three age groups, recruiting a total of 24 participants for interview.
94 Research Assistant
One research assistant, a medical school student, was recruited to help the researcher in finding prospective participants as well as helping with potential language barriers during the interviews. Since most of the participants were Javanese, with some are speaking the Javanese language, and considering the researcher’s own ethnicity is Sundanese, a different part of Java with different language, the researcher needed the assistant to translate several terms of phrase that he found difficult to comprehend. However, due to being a student, the assistant was only able to help the researcher in her available time between studies.
The research assistant was also important in assisting the interview in regard to conducting interviews with the female participants. An issue that will is explored in the Ethical section of this chapter.
Data collection
Special consideration has been taken with regard to sampling and collecting the data for the study, given the fact that Indonesian people are not been familiar with the practice of filling in questionnaires without assistance or returning completed questionnaires by post. Within Javanese culture people prefer to have personal face-to-face communication as it is considered a more respectful way of communicating. Thus, direct approach is considered to be a more appropriate way to access respondents.
The researcher and the research assistant are going to wait in the waiting room, and based from the information from the nurse in charge will approach the prospective participants whilst they are waiting to be seen by the physician or waiting for the medicine in the pharmacy. Verbal consent will be gained before the participants participated in completing the questionnaires. A translated patient information sheet (Appendix 4) explaining the whole study (with the researchers contact details), along with the two questionnaires (Appendix 9 and 10) will be distributed by the researcher or the assistant within the waiting room at the out-patient clinic. Before completing the questionnaires, participants are going to be given time to read the information sheet or if they preferred, to listen to the explanation made by the researcher or the research assistant. Then, the participants will be given ample time to consider their participation
95 and to withdraw from the study. Participants would have the option to take the questionnaires home and complete them and return them to the clinic at a later date if they required more time to decide whether to be involved, or they could complete them in the clinic on the same day. Another consideration for this approach is the time frame for data collection. The researcher was funded to conduct the study by a scholarship that required him to complete within a three year time frame. Therefore, any decisions regarding the duration of data collection were significant. It was agreed by the researcher and the supervisor to conduct data collection process in a three month period.
Data Analysis
The screening questionnaires provided quantitative data, which served two main objectives. Firstly, these tools of self-care and religiosity were used to identify the overall levels within the sample group for the interviews, enabling identification of various level of self-care activity and religiosity. The SDSCA and the Muslim Piety questionnaires results were used to inform the classification of participants into four groups based from different levels of religiosity and self- care; highly religious and self-care, highly religious and less self-care, less religious and high self- care, and less religious and self-care. However, to gain an accurate and varied representation of participants, discussed further in the findings chapter, the classification was amended into three levels of high, moderate and low. Furthermore, along with the progress of data collection and preliminary analysis of the participants’ characteristics, purposive sampling technique was considered more appropriate in answering the research questions, to gain wider and richer participants in the study.
Secondly, the results from the tools also served as additional data that informed and support the categories and themes that emerged from the semi-structured interviews. Indeed, the end result from data analysis will be generated from the triangulation of quantitative data into the qualitative data, which will enrich the qualitative data and put the findings into a more social context.
The interview questions were qualitative in nature, exploring the lived experience of managing diabetes for Muslim patients through the patient’s own stories. The interview transcripts were
96 analysed using a thematic and content analytical method (Graneheim & Lundman, 2004). Following reading and re-reading the transcripts to explore the meaning of the texts, there were several steps taken in adopting this approach.
1. Determining the meaning unit. A meaning unit is a collection of words or sentences that relate to each other through their content and context (Graneheim and Lundman, 2004). Meaning units are extracted from the manifest (visible and obvious components of the text) and latent content (relationships that required interpretation of the underlying meaning of the text), which were extracted and coded, using phrases, words and statements that related to a particular concept surrounding self-care and/or religiosity. The utilization of latent content was considered important particularly in Javanese culture since it tends to avoid expressing different opinions and keeping true feeling to oneself (Magnis-Suseno, 2013).
2. The next step involved the process of reducing, or condensing the meaning unit into smaller chunks of text. This included the process of shortening the meaning unit without diminishing the meaning (Miles et al., 2014) .
3. The third step was the process of abstraction. This step included the process of generating codes, categories and themes.
Determining the codes was considered important since this ‘allows the data to be thought about in new and different ways’ (Graneheim & Lundman, 2004 p. 107), which then, provided the way to the next step of classification of the codes with similar meaning into a higher level of classification. Thus, as Saldana (2009) points out, codes ‘represent and capture a datum’s primary content and essence’ (p.3). The example of generating codes can be found in the Appendix 16.