Caribbean Exploratory [NIMHD] Research Center of Excellence

University of the Virgin IslandsSchool of Nursing

Grant Support: National Institute on Minority Health and Health Disparities, NIH (# P20MD002286).

The Caribbean Exploratory [NIMHD] Research Center of Excellence and Global Health Research Collaboration:

Protecting Haitian Women and Children  Earthquake Survivors from Violence and Abuse 

PRESENTERS: Faye Gary, EdD, RN, FAAN,

& Cheryl Killion, PhD, RN, FAAN,

Case Western Reserve University

Gloria B Callwood, PhD, RNUniversity of the Virgin Islands

Session III: Use of Focus Groups to Assure Cultural and Linguistic Appropriateness in Research

ObjectivesAt the conclusion of this presentation participants will be

able to: 1. Describe advantages of using qualitative (focus group)

methods in cross cultural and international research

2. Identify barriers to conducting focus groups in cross-

cultural and international research

3. Identify outcomes of focus groups for designing and

implementing research in a foreign country

4. Describe implications of focus group use for future

research, practice and policy in cross cultural and cross

national research

Introduction

• Purpose of Using Focus Groups

-Complement other Assessments of Situational

Analysis

-Establish Groundwork for Community Based

Participatory Research

Process of Conducting Focus Groups

Developed Interview Protocols

-Literature Review

-International Reports:

International Rescue Committee (IRC)

Pan American Health Organization (PAHO)

Identified and Recruited Sample

-Administrators, Directors,

Service Providers

-Community Leaders, Youth Group

-Survivors

Process of Conducting Focus Groups

Sought Permission/Secured Consent

Conducted Focus Groups

-Audio Recorded

-Interpreter Facilitated

Focus group: Community Youth Group

Focus Group: Residents of Tent City

Focus Group: Residents of Tent City

Advantages of Focus Group in Cross Cultural and International Research

Understanding health services utilization, availability, potential interventions• Provides insight into intra and inter organization

networks

• Clarifies terms and conditions: Identify mismatches between language and practices used by target audience, researcher, policy makers, and service providers

• Amplifies, clarifies, and triangulates findings from other assessments in situational analysis

Example:

Participants reviewed IRC Recommendations

• Example of IRC Recommendation:

Create dedicated entry points where child and adolescent

survivors can access specialized services safely and

confidentially

• Examples of Related Focus Group Questions:

What are strengths within your organization that can be

drawn on to insure that this recommendation is put into

place?

What are the barriers and challenges to implementing

this recommendation?

Benefits of Focus Groups for Participants/Partners in Research Process

• Allows for participants to compare and contrast their individual and collective experiences

• Allows for exploring the nuances and complexities of participants’ attitudes and experiences

• Allows for gaining insight into intra-group nuances and communication styles

Example:

Group members became engaged in a heated exchange about how the disabled were treated.

Benefits of Focus Groups for Participants/Partners in Research Process

• Allows for gaining a better understanding of participants’ social and cultural worlds

• Serves to culturally anchor the research

Example:

Survivors residing in a tent city were asked about how they usually spent their day:

Response: “Swatting mosquitos!”

• Establishing trust

• Being Respectful

• Being Prepared

• Being Flexible/ Allowing for the Unexpected

• Engaging in De-briefing

Strategies for Developing Researcher Confidence and Sensitivity in Conducting

Focus Groups

Team Takes Lunch Break Between Groups

II: Barriers to Conducting Focus Groups in cross-cultural/international research

• Challenge organizing groups at a distance• Long distance Communications challenging

– Telephone– Email

• Determining who should participate– Driven by project aims/goals

• Making contact with potential group members– Reliance on previous contacts– Level of priority for addressing our concerns

• In person negotiations most effective

•e. Anticipating and addressing language and cultural barriers in Haiti project•Identifying barriers to cross-cultural and international research•Language

Language barriers

• Haitian Creole and French are Haitian official languages (1987 constitution change)– Estimated 9/10 Haitians speak only Creole– Haitian elite fluent in French

• Team members have limited command of Haitian Creole and French– One team member has some understanding of

spoken Creole– One team member has moderate understanding of

French

•and addressing language and cultural barriers in Haiti project•barriers

Addressing Language Barriers

• All study documents translated from English to French and Creole

• Haitian National residing in Florida with close ties to Haiti engaged as interpreter– Travelled with team– Invaluable in suggesting & facilitating contacts– Interpreted meetings with contacts and focus

groups

 

•Identifying barriers to cross-cultural and international research•Language barriers•Addressing language barriers through use of interpreters and translators•Identifying barriers to cross-cultural and international research•Cultural barriers•Addressing cultural barriers -

•in Haiti project

Addressing Language Barriers

• Focus Groups digitally recorded– Back up to field notes

• Recordings downloaded to computer– Transcribed by Certified translator

• Information used to refine approach to project

Cultural Barriers

Social and political realities interwoven into cultural mores• Poorest country in western hemisphere • Roman Catholic primary religion

– Protestant sects emerging• More NGOs in Haiti than any other nation• In rural areas family of 6 earn less than $500.00/year• Many vendors

– Evidence of resilience and hard work– Internal markets with mostly itinerate female traders– Sitting On side of road– Walking with baskets of goods on their heads– Many vendors side by side selling same products

•Addressing cultural barriers -Security and privacy concerns e. Anticipating and addressing language and cultural barriers in Haiti project

•Haiti project•Identifying barriers to cross-cultural and international research

Cultural Barriers• Haggling over money

– No straight forward response to inquiries about cost of doing business

– Multiple NGOs raise expectations of higher remuneration • Hustling

– At airport– On streets

• Small emerging middle class• Smaller wealthy elite• Few public schools (10%) most religious or NGO

– Parents must pay to send children to school.– Most stop school by 7th grade– Literacy rate estimated as 61%

Cultural Barriers• Many cars(said mostly owned by NGOs) and traffic

jams yet most of the population walk• Poor public transport system

– Road sides packed with persons –children and adults- walking

– Difficult for those in outlying camps to get essential needs met

• Colorful art abounds– On busses (called ‘tap taps’)– On walls – Art work for sale line streets

Addressing Cultural Barriers

•Language barriers

Security and privacy concerns• Police, in general, not visible

– Exception: President elect making tour of Port au Prince

– Main thoroughfares blocked; many police cars and motorcycles parading

• Hotel where focus groups held– In central Port au Prince– surrounded by high wall– Check point for entering grounds

• Important to have trusted driver– Almost impossible for person unfamiliar with Haiti

to drive oneself– More difficult with debris that clutter roads

• Important not to travel alone

•in Haiti project•Identifying barriers to cross-cultural and international research•Language barriers•e. Anticipating and addressing language and cultural barriers in Haiti project

-Security and privacy concerns e. Anticipating and addressing language and cultural barriers in Haiti project

-

Security and privacy concerns• Upscale Haitian residences gated• Security persons stationed at hotels, guest

houses. • Visitors have been targeted

– Reports of kidnapping– Reports of violence

• Triggered US Embassy alerts • Haitian travelling companion

– Served as safety monitor

Anticipating and addressing language and cultural barriers in Haiti project

 • Modify instruments for linguistic nuances and reading levels

• Engage native Haitians – To record audio versions of instruments

• Hire– Local agent

• To navigate the socio-cultural-political landscape and assist in negotiating contracts

– Local PI– Local Project Coordinator– Local data collectors

Part III: Analysis of focus group data in cross-cultural and international research

Use of focus group data to inform research process

- Establish rapport and trust with community

- Assist in identification of potential members of the Advisory Coalition - Elicit help in recruiting, screening, and retaining participants in the study

- Seek input for developing culturally specific interventions and related materials

•and cultural barriers in Haiti project•language and cultural barriers in Haiti project

Analysis of focus group data in cross-cultural and international research

Use of focus groups for dissemination of research findings

• Provide written reports of key findings to key stakeholders

• Present preliminary findings at local community organizations and professional groups (in consultation and collaboration with the Advisory Coalition)

• Present findings at local and national conferences• Publish articles related to the findings and

research process in national and international journals

Part IV: ImplicationsFuture Research

• Confidentiality Issues Abound– Please be advised that although the researchers will

take every precaution to maintain confidentiality of the data, the nature of focus groups prevents the researchers from guaranteeing confidentiality. The researcher would like to remind participants to respect the privacy of your fellow participants and not repeat what is said in the focus groups to others.

University of Massachusetts, Amhurst, 2010

• Focus Group data is a excellent methodology

• Can be used to capture the complexities of the human condition, rather than reducing it—for the purpose of understanding the situation and its dynamics– Antecedent Factors– Enabling Factors– Reinforcing Factors

Culturally Appropriate Issues• Identify and address barriers to research

participation…thinking beyond study completion…focusing on “terms of engagement.”

• Intensity of contact ( letters, cards, notes, etc.)• Early identification of potential barriers• Identify individuals who are critical to the

success of the research, or for the individual who needs health care

• Identify attitudes (positive & negative) about previous interactions with researchers, caregiver professionals, and obstacles that were/could become barriers in the engagement process

Terms of Engagement• Making plans for participating in research• Overcoming concrete barriers

(transportation, time constraints, child care concerns)

• Developing foundations for trusting & collaborative relationships

• Being responsive to “life situations” that could negatively impact participation in the research, or help seeking behaviors

Recognizing Advantages • Research

– Limited understanding of the use of research in improving the lives of individuals and families

– Distrust regarding the use of information gleaned from the research

– Distrust of individuals who conduct the research in resource limited communities

– Community members might not share there “true” life experiences with “outsiders””

Research• Collaborative interactions are essential• Formation of alliances could help to

develop

& identify solutions to otherwise complex problems

• Provide continuous training and supervision for individuals engaged in the research process

Practice• Many times individuals are referred to

practice without the knowledge of the need for treatment

• Impoverished individuals & communities are profiled as “high need” & “low treatment” participation outcomes– Alliances, and intense engagement

activities are key elements for increasing participation in treatment and research

ImplicationsPractice

• Identification and elimination of gaps in services for survivors

• Improvements in case management and psycho-social services for survivors

• Advances in health and service providers’ training on standards of care for survivors

•e. Anticipating and addressing language and cultural barriers in Haiti project

Policy• First, effective participation in research and

treatment, clinical trials, community-based studies are essential for policy!

• Second, treatment outcomes, culturally relevant interventions, consumer/study participant interpretations are also required

• Then, Policy follows: Relevance for the target population must be the major goal– Without a new and novel approach,

research, treatment, and policy will never adequately service individuals and communities with the greatest need.

ImplicationsPolicy

• Implement changes in protocols and procedures that facilitate access to care(and prosecution of perpetrators)

-Medical certificates

• Partner with international organizations to facilitate capacity building and technical assistance sustainability

• Advocate, with local and international agencies, for legislative reforms related to protecting survivors

Thank You !!Questions?