Navigating Nuances of Language and Meaning: Challenges of Cross-Language Ethnography Involving Shona Speakers Living With Schizophrenia

Defining focused ethnography: Disciplinary boundary-work and the imagined divisions between 'focused' and 'traditional' ethnography in health research - A critical review

This article offers the first critical review of focused ethnography, an increasingly popular research method across health disciplines. Focused ethnographers, we argue, exemplify the practice of methodological boundary work, defining their method in contrast to the 'traditional' ethnographic approach of anthropology and sociology. To examine this boundary work, we collected two samples of health research articles published over the last decade and compared how focused ethnographers and medical anthropologists described, justified, and practised ethnography. We found that the core characteristics most often asserted to differentiate focused ethnography from conventional ethnography were: a more limited study timeframe and scope; a limited subpopulation sample; more concentrated research questions; the inclusion of insider researchers; and more orientation towards applied results. We show, however, that these are imagined binaries that fail to map onto actual differences of practice in the two samples and which obscure many similarities between them. By contrast, we identified four alternative differences between the two methods of ethnography. These centre on understandings of 'research time'; the very meaning of ethnography; the relationship of researchers to 'data'; and the presumed best method of social intervention. We therefore define focused ethnography as a versatile method of ethnography that attends to specific epistemological expectations within the health sciences regarding valid proof and empirical description, the boundaries of research, the nature of research relationships, and the duty to improve biomedicine. Ultimately, our study highlights that methodological boundary-work matters, because assumed differences and unexpressed misunderstandings can prevent productive dialogue and fruitful collaboration between disciplines to address pressing health problems.

What Makes People With Chronic Illnesses Discontinue Treatment? A Practice Theory Informed Analysis of Adherence to Treatment among Patients With Drug-Resistant Tuberculosis in Pakistan

BACKGROUND

Non-adherence to treatment is a frequently observed phenomenon amongst those on long-term treatment for chronic illnesses. This qualitative study draws upon the tenets of 'practice theory' to reveal what shapes patients' ability to adhere to the demanding treatment for drug-resistant tuberculosis (DR-TB) at three treatment sites in Khyber-Pakhtunkhwa (KP) province of Pakistan.

METHODS

This qualitative study involved observation of service provision over a period of nine months of stay at, and embedment within the three treatment sites and in-depth interviews with 13 service providers and 22 patients who became non-adherent to their treatment.

RESULTS

Consistent with the extensive research based on the barriers and facilitator approach, both patients, and providers in our study also talked of patients' doubts about diagnosis and treatment efficacy, side-effects of drugs, economic constraints, unreliable disbursements of monetary incentive, attitude of providers and co-morbidities as reasons for non-adherence to treatment. Applying a practice theory perspective yielded more contextualised insights; inadequate help with patients' physical complaints, unempathetic responses to their queries, and failure to provide essential information, created conditions which hindered the establishment and maintenance of the 'practice' of adhering to treatment. These supply-side gaps created confusion, bred resentment, and exacerbated pre-existing distrust of public health services among patients, and ultimately drove them to disengage with the TB services and stop their treatment.

CONCLUSION

We argue that the lack of supply-side 'responsiveness' to patient needs beyond the provision of a few material inputs is what is lacking in the existing DR-TB program in Pakistan. We conclude that unless Pakistan's TB program explicitly engages with these supply side, system level gaps, patients will continue to struggle to adhere to their treatments and the TB program will continue to lose patients. Conceptually, we make a case for reimagining the act of adherence (or not) to long-term treatment as a 'Practice.'

Reflecting on 'insider' and 'outsider' positionality when undertaking culturally sensitive research with young Pakistani men: insights from a female researcher

BACKGROUND

Conducting culturally sensitive research into male experiences can be challenging for female researchers. Despite this, there are very few published reflective accounts of how they have overcome these difficulties.

AIM

To illustrate a female researcher's challenges in conducting research into young men's experiences of puberty in Pakistan and highlight the strategies used to overcome these.

DISCUSSION

An important challenge for the researcher was creating an environment in which participants felt able to share their experiences. This was overcome by the incorporation of the experiences of public involvement contributors in the development of the project, offering a choice of interview format to participants and other solutions driven by the 'insider' position of the researcher. The researcher's 'outsider' role as a mature and pregnant woman appeared to create a 'safe' environment, allowing the young men to openly share their personal experiences.

CONCLUSION

Female researchers can successfully conduct culturally sensitive research with young men in patriarchal societies such as Pakistan. The key is to be aware of potential cultural issues and to use any insider/outsider positionality to the greatest effect.

IMPLICATIONS FOR PRACTICE

In addition to adapting procedures, such as gaining trust, building rapport and assuring a non-judgemental and comfortable environment, the 'outsider' position of the female researcher should be given due consideration when undertaking culturally sensitive research with men.

Engaging diverse community members to enhance analysis and interpretation: processing qualitative interview data

As the USA becomes more diverse, the inclusion of patients from diverse backgrounds in research becomes ever more important to ensuring a complete understanding of the patient experience in primary care. Language and cultural barriers are important areas in which researchers face substantial challenges. Primary care researchers need tools and approaches to include diverse communities in qualitative interviews. Here, we describe one way primary care researchers can apply an adapted, engaged transcription and interpretation method in qualitative research to improve retention of nuance and meaning across language and cultures, specifically with non-English, non-Spanish-speaking resettled refugees. We also discuss how the approach provided additional information that increased the validity of interpretation and analysis and improved the retention of nuance in a qualitative primary care study. The methodological and practical value, scope of application and potential limitations and improvements of this method through future research are addressed.

"Seeing a Brighter Future" - Experiences of Adolescents with Common Mental Disorders Receiving the Problem-Solving Therapy "Youth Friendship Bench" in Zimbabwe

In Zimbabwe common mental disorders are prevalent among adolescents and the treatment gap is large. The recently introduced Youth Friendship Bench intervention (YouFB) addresses this gap by task-shifting youth lay health workers to offer a culturally contextualised, manual-based, six-session problem-solving therapy to adolescents, 16-19 years of age. The aim of this study was to explore participants´ experiences of YouFB to attain a first insight into this novel intervention. Interviews with nine adolescents were analysed using qualitative content analysis on a latent level. The experience of YouFB was positive, perceived to offer hope and relief from feelings of isolation and uncertainty, increase manageability of problems, and contribute to feelings of autonomy, resulting in a feeling of optimism about the future. The notion among participants that this brief intervention had such a positive influence on their lives, sparks interest because of its applicability in low-resource settings.

Methods, Ethics, and Cross-Language Considerations in Research With Ethnic Minority Children

BACKGROUND

Qualitative research seeking the perspectives of minority children on child health issues such as childhood obesity and healthy weight care is limited, especially in nursing research.

OBJECTIVE

Our objective is to share methodological, ethical, and cross-language knowledge gained from conducting an ethnonursing research study. This study focused on providing a voice for ethnic minority children in childhood obesity literature.

METHODS

The purpose of the study was to discover cultural influences on healthy weight care in children of Burmese refugees of Karen ethnicity. Researchers may exclude children of ethnic minorities from studies because of the distinct challenges in conducting cross-language research and research with children. We critically examine these challenges. The challenge of being a stranger was addressed by a period of immersion in the children's activities prior to data collection, in addition to volunteering as an English teacher with Karen adults. The immersion period was crucial for developing the trust needed in child-inclusive research and research in ethnic minority communities. The challenge of designing an inclusive study with families who experience language barriers was addressed with an interpreter who not only spoke Karen but was also a part of the Karen community. The interpreter provided the authentic sociocultural language equivalence needed for the study's rigor. Ensuring the child's voice was clearly heard was addressed with member checking. Methodological changes necessitated by a pandemic were a distinct challenge discussed in detail.

RESULTS

We described methods useful for nurse researchers seeking transformative knowledge to reduce health disparities in childhood obesity. Nurse researchers may use these methods related to cross-language research and child research for designing research inclusive of minorities with language barriers.

DISCUSSION

The perspectives of children from ethnic minorities are needed to inform culturally congruent healthy weight care for their communities. The goal in providing transparency of the difficulties, successes, and recommendations for methods in research with children of Burmese refugees is to encourage more nurse researchers to work with marginalized groups. Nurse researchers can inform evidence-based, culturally appropriate interventions to address health inequities of minority communities by including the voice of children from these communities.

Ethnographic Insights into the Quality of Life and Experiences of People Living with Schizophrenia in Harare, Zimbabwe

Schizophrenia is a complex and severe mental disorder affecting more than 20 million people worldwide. This study used focused ethnography to explore the everyday lives of 18 people living with schizophrenia in Zimbabwe and its impact on their quality of life (QOL). Data were collected using semi-structured interviews, observational fieldwork, and the short form of the World Health Organization QOL-BREF questionnaire. Those aged 20-40 years experienced poorer QOL than older people. Family dislocation, living with stigma and discrimination, cost of medications and limited and variable access to treatment and support disrupted participants' ability to enjoy life and function socially.

Tool for the Meaningful Consideration of Language Barriers in Qualitative Health Research

Individuals who experience language barriers are largely excluded as participants from health research, resulting in gaps in knowledge that have implications for the development of equitable policies, tools, and strategies. Drawing on the existing literature and on their collective experience conducting occupational health research in contexts of language barriers, the authors propose a tool to assist qualitative researchers and representatives from funding agencies and ethics review boards with the meaningful consideration of language barriers in research. There remain gaps and debates with respect to the relevant ethical and methodological guidance set forth by funding agencies and institutions and proposed in the scientific literature. This article adds to knowledge in this area by contributing our experiences, observations, and recommendations, including around the issue of conducting research in contexts of more or less linguistic diversity.

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Strategies for overcoming language barriers in research

AIM

This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier.

DESIGN

Discussion paper.

DATA SOURCES

Research methods papers addressing cross-language research issues published between 2000-2017.

IMPLICATIONS FOR NURSING

Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into "big data" systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes.

CONCLUSION

Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research.

IMPACT

This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.