The coeliac disease quality of life Survey (CD-QOL)

This study involved two phases – an online questionnaire and interviews.

Following ethical approval, an invitation to complete an electronic questionnaire was sent to educational supervisors. Subsequently, interviews were conducted with eighteen GPs teaching in multilevel teaching practices.

5.4.1 Identification of study population

A list of our GP teachers for year 3 or year 4/5 were identified from our tutor database. This generated a list of one hundred and ninety-nine names. However, as some of our tutors teach for both year 3 and year 4/5, duplicates were

removed. This resulted in a study population of one hundred and eighty GPs.

5.4.2 Questionnaire purpose and design

An online questionnaire was designed (SurveyMonkey, 2017) and the content refined based on feedback (Appendix II). The questionnaire aimed to serve two purposes:

1. To collect data on relevant characteristics of our tutors and their

practice populations (age, gender, full or part time working, practice list size, remote or rural practice, level of practice and individual teaching involvement).

2. To identify tutors who would be willing to be interviewed for the second part of the project.

5.4.3 Questionnaire participant recruitment and response rate

An email was sent via Survey Monkey to the list of supervisors, inviting them to participate in an online questionnaire about the teaching they do in practice (Appendix III). A challenge with web and email surveys is achieving an adequate

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response rate (Scott et al., 2011). Although postal surveys may be more

effective in achieving a good response rate from GPs (Pit, Vo, & Pyakurel, 2014), an electronic questionnaire was chosen over a paper-based option for a number of reasons. Firstly, our study population would all be familiar with electronic communication and internet use as part of their daily work. Secondly, I was confident that we had accurate contact details for all of the study population as our mode of regular communication with our supervisors is via email. Thirdly, use of Survey Monkey would enable me to easily view and interpret the data. Finally, there was no financial cost to use Survey Monkey.

With the response rate in mind, I adopted a few of the strategies outlined by McPeake et al (2013) to try and maximise response rate.

1. I kept the survey as brief as possible, only collecting data that I felt contributed to understanding of the study population.

2. In both the email subject line and the body of the email, I emphasised that the questionnaire should take less than five minutes to complete. 3. I embedded the first question of the survey in the invitation email. As there is evidence that reminders increase response rate (Sahlqvist et al., 2011), I decided to send one reminder message. McPeake et al (2013) suggest sending two reminders but I was mindful of the volume of emails a GP can receive in a working day so I felt one reminder was more appropriate. The original email invitation was sent out on February 9th _{2017 and the reminder on} February 23rd _{2017. By February 23}rd _{2017, Survey Monkey identified that}

seventy-nine tutors had completed the questionnaire. Based on verbal feedback from a number of tutors who had completed the survey, I edited the reminder message to suggest that the survey typically only took two minutes to complete and not the five as originally suggested.

Reviewing final figures, all tutors who clicked through to the survey completed it. Just under a third of tutors did not open either of the emails and an overall response rate of 60% was achieved (n = 108/180). (see Table 5-1)

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Table 5-1 Questionnaire response rate

5.4.4 Interview schedule

An interview schedule based on ASA was designed. It contained nine overarching open questions and a set of follow up questions for each of these if required (Appendix IV)

5.4.5 Pilot interview

As one of the willing participants identified was a GP in my practice, it was proposed that his interview should be a pilot interview to test several aspects of the study:

1. Recording equipment 2. Interview schedule

3. ASA mapping of an interview

He was chosen as, although there are benefits to insider research, it was felt that I would be too close to this particular case. His data was not included in the formal analysis. As a result of the pilot, minor modifications were made to the interview schedule. This specifically related to the use of AT terminology within the interview questions. Although I was clear what was meant by terms such as tools and rules, this was less clear to someone not versed in AT. Therefore, the questions were reworded to include a brief description of the terminology.

5.4.6 Interview participant recruitment

A list of forty-two medical student supervisors working in postgraduate training practices was identified. Each individuals’ responses were reviewed and this

Questionnaire response rate

Email invitations sent 180 100.0% Initial response rate (pre reminder) 79 43.9% Email invitations opened (final) 124 68.9% Clicked through rate (final) 108 60.0% Questionnaires completed (final) 108 60.0% Email invitations unopened (final) 56 31.1%

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generated a list of thirty-four supervisors willing to be contacted re interview. An invitation email was sent at the start of June which included a participant information leaflet (Appendix V). Interviews took place in June and July 2017. By the end of June 2017, seventeen tutors had responded agreeing to take part and interviews were scheduled. This included one tutor who contacted me directly to advise that he did not wish to complete a questionnaire but would be happy to be interviewed. His demographic data emerged during the interview so is represented in any interview participant figures reported.

Following the initial allocation of interview dates, five further tutors came forward expressing an interest. It was agreed to conduct the initial scheduled interviews and review the data before deciding if their participation would be appropriate.

5.4.7 Number of interviews

There are a range of opinions on how to decide if “enough” data has been collected and I found Bryman’s thoughts on this particularly helpful (Baker & Edwards, 2012). He suggests five factors to be considered:

1. The issue of saturation

2. What are the minimum requirements? 3. The theoretical underpinnings of the study 4. The heterogeneity of the population

5. The breadth and scope of the research questions

The concept of saturation originated from grounded theory (Glaser & Strauss, 1967) and recommends that interviews should continue until no new insights are emerging. It is not possible to know at the outset when this point will be and it could be argued that you never truly know that you have reached it. However, for the purpose of this thesis, I began by reviewing the data as my interviews progressed. Transcribing, listening back to the interviews and familiarising

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myself with them through drawing activity system maps for each interview (see 5.5) enabled me to reflect on data as it emerged.

There is not a fixed number of interviews required for my doctorate, rather an expectation to answer the questions posed. This study focuses on a narrow study population and although all participants were GP teachers, there was diversity amongst both the GPs and their practices. From a teaching perspective, I wanted representation from practices where one GP led on all teaching, as well as

practices where different GPs led on different levels, as I was curious about how this influenced the activity of teaching in those practices. The characteristics of the interviewees are described in Chapter 6.

By positioning my study in an interpretivist paradigm, I reflect my belief that there is no one truth to be found and my choice of a collective case study approach aligns with that. While aiming to better understand the “reality” of the continuum of medical education in MLL GP practices, it was important that participants reflected the diversity of those GPs and practices. Therefore, through reflection on participant characteristics and data as it emerged, I felt comfortable that I had conducted “enough” interviews to address the questions posed.

5.4.8 Interview Process

Semi-structured interviews with my seventeen participants were audio recorded and transcribed. Fourteen interviews were conducted in person and three were conducted over the phone. Participants were given the choice of how and where their interview was conducted. Following each interview, I wrote

contemporaneous notes reflecting on the interview and recording any emerging thoughts related to the project overall. In subsequent interpretation and

analysis, these notes helped establish a context for each interview and shaped my evolving understanding of the data.

I transcribed the first five interviews myself. This facilitated further review of the suitability and usefulness of the interview schedule and identified the need to further refine some of the questions related to AT terminology. Further to this, transcribing my own early interviews enabled me to review and improve my

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interview technique. While not a novice researcher, I believe my interview skills improved as the project progressed.

At a relatively early stage it became apparent that interviewees struggled with the concept of the continuum. As this was a fundamental part of the research question, it was decided not to modify this question. However, through their responses to other questions I was able to glean an understanding of how the continuum was represented in these practices (see 7.6.4).