IN-DEPTH INTERVIEWS
This chapter focuses on the use of in-depth interviews as an applied qualitative method in drug use studies. It begins with a brief overview of the technique and continues with a description of the various steps involved in carrying out an applied qualitative study using the in-depth interview method.
3.10:Overview
3.11:What is an In-Depth Interview?
An in-depth interview is a qualitative research technique that allows person to person discussion. It can lead to increased insight into people's thoughts, feelings, and behavior on important issues. This type of interview is often unstructured and therefore permits the interviewer to encourage an informant (respondent) to talk at length about the topic of interest.
The in-depth interview uses a flexible interview approach. It aims to ask questions to explain the reasons underlying a problem or practice in a target group. You can use the technique to gather ideas, to gather information, and to develop materials for drug use interventions.
3.12:Use of In-Depth Interview in Drug Use Studies
One effective way to understand the reasons underlying problem behaviors is in-depth analysis. In drug use studies, areas in which the method can be used include:
! In pilot studies to generate ideas.
!To obtain greater depth of information on a topic of interest as a supplement to data received from other methods, e.g., structured questionnaire.
!To evaluate the impacts of interventions on attitudes or beliefs.
This section will consider only how in-depth interviews are used to gather data to prepare for interventions.
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3.20.Steps in Using In-depth Interview to Study Drug Use Problems
The activities involved in using in-depth interview to study drug use problems can be organized into a series of steps. These are summarized below. A detailed discussion of each step follows the summary.
TABLE 3.1:Summary of Key Steps in Conducting In-depth Interview
Step 1:Plan how you will conduct the in-depth interviews.Step 2:Decide who your respondents will be.
Step 3:Prepare interview guide for each category of informants.
Step 4:Select your interviewers.
Step 5:Train the interviewers.
Step 6:Conduct the actual interviews.
Step 7:Analyse the data.
Step 8:Write a report and recommend intervention(s).
3.21.STEP 1: Plan How You Will Carry out the In-depth Interview
Once the decision to use in-depth interview has been taken, very important planning decisions and preparations are needed. These include designing the study, identifying the target group, preparing for the fieldwork, and collecting and analysing the data.
a.Consider the Need for a Resource Person
Because the technique may be new to most health oriented professionals, one of the first planning decisions to consider is the need for a resource person, particularly if the investigator is not confident enough with the application of the method. Other things to consider before you decide to seek the assistance of a resource person are the size of the study and the resources available to it.
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In a small exploratory study with limited resources, you could rely on a colleague who had used the method before. However, in a big study to ascertain the reasons for some observed problem behaviour, you may need the assistance of a social scientist who is well experienced in the actual use of the method.(See Section 2.10 for more tips on qualities to consider when in need of a resource person).
b.Role of a Resource Person
Essentially, the role of any resource person at this stage will be to assist in planning the technical details of the study. This will include:
!how to obtain the study informants;
!development of interviewing guides;
!how to proceed with the field work;
!training of interviewers and other field staf;
!guidance in subsequent analysis of the field data.
These aspects of the study are very important, and such professional support needs to be seriously considered if the principal investigator is not too confident about the method.
3.22.STEP 2: Decide Who Your Informants (Respondents) Will be
Identifying respondents from whom you can obtain the information you need is a very important part of the study since the sources of information affects the quality of data obtained. You must therefore identify key informants who can provide useful information for the study.
a.Determining Who to Select for the In-Depth Interviews
The first thing to bear in mind is that in-depth interviews take much more time than structured questionnaires. It is therefore not usually practicable to interview a large sample. A typical study might include 3-4 interviews with respondents in each of 4 subgroups of interest, for a total of less than 20 interviews. To account for the small sample size, those selected for the in-depth interview must be people who are well informed about the issue to provide relevant information. Usually informants are selected for in-depth interviews in a purposive manner, that is, people with specific demographic/social characteristics are chosen to represent a defined subgroup.
This involves identifying individuals from the target groups who are and must be knowledgeable about the study topic. Depending upon the nature of the problem and composition of the target population, respondents are selected from various identifiable subgroups. Respondents selected must be fairly representative of the various groups in the study population for this technique to be useful.
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b.Selecting Informants: Some Examples
Let us consider a study about the overuse of antibiotics in the treatment of ARI in children. After deciding to use in-depth interviews, a study team may have identified the following target groups:
!prescribers working in primary, secondary, and/or tertiary health care facilities;
!dispensers working in these same health care facilities;
!mothers with children under the age of five in the community;
!operators of drug outlets in the private or informal sector.
The following example (Figure 3.1) describes two ways in which participants could be selected to represent these target groups.
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Figure 3.1:Examples Showing How Respondents May Be Selected
Example 1:To identify representative prescribers in public health facilities:!List the names and locations of all health facilities in the district separately according to levels, i.e., all community clinics, all health posts/centers, all district hospitals.
!Select a small number of facilities in which the interviews are to be conducted, e.g., 2 community clinics, 2 health centers, 1 hospital.
!In each facility, choose one health worker in each category to be interviewed, e.g., village health worker, officer-in-charge, paramedic, dispenser, or pediatric specialist.
If the information from the selected respondents is not consistent, additional facilities and respondents can be chosen in the same way until the reasons for the inconsistency are understood.
Example 2:To identify representative mothers of children under the age of five recently treated for ARI:
!Contact the selected health facilities in the study district.
!Get a list of children under the age of five treated for recent episodes of ARI (ideally within two weeks preceding the study to enhance recall by mothers who will be interviewed).
!Decide on reasonable number of mothers to be interviewed, e.g. 2 mothers treated at each of five facilities.
!Contact the mothers in their homes and arrange interviews.
If it is not feasible to identify mothers from clinic records, it may be necessary to draw the sample in the community. Village elders or local administration after have lists of families and family members. Families should be visited until two recent cases of ARI are identified.
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c.Hints for Selecting Informants for In-Depth Interviews
Some hints to consider when making your final selection of key informants are:
!The informants should be unknown to the interviewers, if at all possible, in order not to increase the likelihood of their giving biased responses.
!They should not have previous knowledge of the specific issue of study.
!A conscious attempt should be made to select different categories of individuals in each target group, for example, by age, gender, status, education.
3.23.STEP 3: Prepare an Interview Guide for Each Category of Respondents
The guide consists of a list of questions or topics to be discussed by interviewers with respondents in the field. The quality of data obtained depends to a large extent on the quality of questions in the guide. A good guide uses general, non-directive questions or phrases instead of direct questions that may end up in "Yes" or "No" answers. The task of the investigator or team of investigators involves reviewing the study topics to develop questions that will yield relevant responses. Following are suggested stages in developing the interview guide:
a.Framing the Questions
1. List the most important topics to be explored in the study.
For example, for a study investigating the overuse of antibiotics in the treatment of ARI in children, we could list some of the specific topics for in-depth interviews with health workers:
!which particular antibiotics are being used;
!symptoms associated with perceived need for antibiotics;
! reasons for prescribing antibiotics for the common cold;
!reported patient preference for drugs;
!sources of information about antibiotics.
2. Identify relevant subtopics for each of the study topics
Each major topic can be broken into specific subtopics that can be explored during the interviews. For example, in relation to reasons for prescribing antibiotics to treat common colds, we can list the following sub-themes:
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beliefs about respiratory infections;
!efficacy of antibiotics in treating infections.
3.Make a draft of possible questions that could be explored with respondents about these sub-topics.
4. Check each question against the overall study questions and take out those that are not needed to answer one or more of the study questions.
5. Check the questions again to ensure that they can help initiate discussion.
Ensure that your questions are:
!clear and unambiguous;
!simple and easy to understand;
not answerable by a simple Ayes@ or Ano@;
!reasonable and within the experience of the targeted respondents.
b.Construction of Probes
When writing the guide, build in useful "probes" to assist the interviewer. Probes are devices used to prompt a respondent to speak further when an initial question fails to elicit the desired information. Suppose in our antibiotic illustration the following question is asked of a prescriber:
What would your reaction be if you were advised by the District Medical Officer to stop the use of antibiotics in the treatment of ARI in children?
Answer: Well, I guess we'll have to wait and see what happens when the time comes.
Here the respondent avoided answering the question. If his answer is accepted, his attitude about a policy against the use of antibiotics in treating ARI will not be known. It is helpful to anticipate this difficulty, and to construct "probe questions" in advance to cater for these situations.
An example might be:
How would you feel about the DMO issuing such a directive?
The creation of appropriate probes brings a measure of control to a potentially haphazard form of questioning.
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c.Sequence of Topics
In general, the order of topics in in-depth interviews is never rigidly defined. Rather this is left at the discretion of the interviewer and is determined by the flow of the discussion. This is one of the reasons why interviewers need to be well trained in the art of interviewing.
Design the guide in such a way that similar types of information will be elicited from all respondents. However, the particular phrasing of questions and their order or sequence may be re-defined to fit the characteristics of each interview.
Example of Interview Guide
Figure 3.2. shows a list of questions that may be asked in an in-depth interview to investigate the use of antibiotics by prescribers in treating ARI in children. The interview may not necessarily follow this order. More examples of in-depth interview guides are provided in annexes.
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FIGURE 2:Example of Interview Guide
Use of Antibiotics in the Treatment ofcommon cold (ARI) in Children.
Interview Guide for Prescribers
Introduction: Self introduction, name and general affiliation
Purpose of Interview
We are aware that common cold (ARI) is one of the common health problems of children in this community. We are interested in knowing your views about this problem and how it is managed. It will be appreciated if we could spend some time together to discuss this issue.
Interview Begins
Clinic Experience
How long have you been working as a (doctor, paramedic, etc.)?
How long have you been working at this clinic?
How many patients do you see in a day?
How many of these patients are under the age of five?
Diagnosis
Could you please describe how respiratory infections present themselves in children in this community?
How do you decide on severity of case?
What are some of the symptoms of severe respiratory infection?
Is it hard to recognize these symptoms?
Treatment
How do you usually treat mild respiratory infection in children?
Do you always treat coughs this way or do you sometimes treat them differently?
If yes: How do you decide on how to treat a cough?
Do mothers sometimes ask for particular medicines?
Use of Antibiotics
When should someone prescribe an antibiotic for a child with common cold?
Which antibiotics are the best to prescribe?
and so forth
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3.24. STEP 4: Select Your Interviewers
The success of an in-depth interview depends in large part on the qualities of the interviewer. Much more communication skill is required than would be needed for administering ordinary questionnaire interviews.
The role of the interviewer is to keep a discussion going by asking useful questions until he or she gets an appropriate response. This demands certain qualities in those selected for the task. The following qualifications are useful to consider:
!Formal training in social science or interviewing is an advantage though not a pre-requisite.
!When social scientists are not available, people with secondary education in health- related areas such as nurses and community development workers or social workers with some experience in interviewing may also be suitable.
Good interviewers are people who easily gain peoples= confidence and cooperation, speak clearly, and are good listeners. Additional qualities to consider are:
!knowledge of drug use issues;
!self confidence;
!ability to establish rapport;
!confident but not pompous;
!unassuming personality;
!politeness;
!articulate enough to prompt respondents to talk.
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3.25.STEP 5: Train the Interviewers
Training provides an opportunity to prepare the field team for their task. All field workers involved in a study attend a common training session so they can start with a common understanding of study objectives and procedures. Even experienced interviewers need to be trained, since each study will have its unique objectives, target groups, and study instruments.
a.Duration of Training
Training should be long enough to allow all aspects of the study to be tackled before the actual field work. The length of time may vary depending upon the size of the study and calibre of the field team. In general, however, this may take two to three days.
An ideal location free from interference with the daily work routine of the field team must be secured for the training sessions. In order not to disrupt the sessions all materials and provisions, including snacks and lunch, should ideally be provided on site.
b.Training Sessions
At the beginning of the training, materials such as the study guides, protocols, and handouts should be given to the interviewers so that they can study them and raise any general queries during the training. The trainer must explain and discuss these materials with the interviewers. The discussion of each material should be allotted reasonable time to make it effective. The trainer should encourage a friendly and conducive atmosphere for free exchange of comments and questions.
The training program can be organized in stages with specific objectives. Prepare an agenda before assembling the interviewers. Sessions will be needed on both theoretical and practical aspects of the study. The theoretical aspects cover topics including:
!outline of the goals and objectives of the study;
!overview of in-depth interviews;
!how to conduct in-depth interviews, i.e., starting, moderating, and ending the
interview;
!how to take notes during interviews;
!outline of possible implementation problems;
!how to analyze the data and write a report.
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The practical aspects of the training involve:
!role plays;
!pilot testing.
Role Play:
Provide an opportunity for each interviewer to role play the interview to gain experience before going to the field. Such role plays are also a great help in evaluating the effectiveness of individual interviewers. Go over the interview guide as many times as there are questions and comments raised by interviewers.
Pilot Testing
Before the actual fieldwork, you should plan to conduct a pilot test in a group similar to the target group in terms of study characteristics. This exercise affords an opportunity for the investigator and the study team to evaluate the appropriateness of the interview guides. It also enables interviewers to put into practice the skills they have learned before the actual interview.
After the pilot test the study team should meet to discuss the experience in the field. Problems relating to the appropriateness, clarity, or ambiguity in the use of the guide, as well as others relating to respondents and the study environment, can then be fully discussed.
Discuss any issues of translation of guides and/or notes at the training sessions. To avoid later problems, ensure that all translations are thoroughly reviewed before the group moves into the field.
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TABLE 3.3:Tips on How to Conduct an In-depth Interview
The "Dos"!Begin interview with a friendly and familiar greeting.
!Listen with attention to capture every piece of information from respondents.
!Explore key words, phrases, idioms, terms as they occur in the discussion.
!Listen to impressions, topics avoided by informant, deliberate distortions and misconceptions or misunderstandings. Take prompt action to explore each of these. Where appropriate, use "probes."
!Ensure a natural flow of discussion by guiding informant from one topic to the next.
!"Play dumb"(be silent) to give the respondent plenty of room to talk.
!Be open to unexpected information.
"The Don'ts"
!Influence or bias responses by introducing one's own perceptions or asking leading questions which encourage a particular response.
!Move too quickly from one topic to the next
!Interrupt the informant.
!Do not mislead about the subject matter in order to obtain information.
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