Methods and Procedures
Description of Entry: Entry into the community will begin in the first week when I arrive in Wiamoase. The first week in Ghana will be largely a week of observation, writing and beginning to interact with people around me, but entry into the clinic will be different. After the first week of being in Wiamoase, I plan on approaching the health center and asking if I can volunteer there as I conduct my study. Because the IRB necessitates that I ask for permission from the health center to conduct my study, if I haven’t received that permission in an email or letter before then, I will request to meet with the administrator and request verbal and written consent to conduct the study. Once I receive that permission, I’ll work to develop relationships with the clinic staff and patients, making personal observations from my participation in the clinic and try to identify people that would be good resources for interviews in the clinic. When I’m not in the clinic, I hope to participate in many varied cultural experiences developing rapport and relationships with people in the community and get referrals for people or places that associated with different capitals and begin establishing prospective contacts from those referrals.
Description of Informants: To get an ideal understanding of the resources under each capital and any issues associated with them, I will need to include in clinic informants as administrative, staff and patients of the clinic, as community informants I will interview people involved in cultural, political and social organizations. My project is limited to people 18 years old or older and is specific to people involved in aspects of the community that relate to the capitals, regardless of their position within the community. I will select people that have been involved with the health center or community for at least a year. All participants responsible for the telling of specific items will be required to sign an interviewee’s release form included in Appendix F.
Description of Sampling and Recruitment:
Sampling: I expect to interview 20-25 people, involved in some aspect of these seven capitals: 1-2 administrative individuals about human and financial capital issues; 6-8 staff members about human, natural and built capital topics; and depending on availability and openness of patients to interviews, 4-8 individuals about human and built capital topics. I also hope to interview 2-3 people involved in the political organization of Wiamoase, 2-3 cultural figures that can explain the culture and history of Ashanti people and Wiamoase, and 1-2 traditional health practitioners to understand the cultural and natural aspect of health. While these numbers will be flexible according to availability and feasibility in the field, the variety demonstrates my goal to incorporate many people in the community into my research and understanding of these capitals. Because of the specific nature of the capitals, I will need to target people to interview that are related to the capitals. I will obtain a sample of informants by convenience, referral and snowball sampling.
Recruitment: As I explained in the “plan of entry” section, I will begin my research within the health center by getting permission from Administration to volunteer there. While developing relationships with people there, I plan to ask preliminary questions about the clinic and explain that it relates to my study. Those that seem interested in helping answer my questions I will eventually ask to interview. In the event they can’t answer my questions, I’ll ask for a referral of someone who could and approach them about an interview. I’ll also use my time in the health center getting to know patients, asking them where they are from and if they come to the clinic often. If some seem particularly familiar with the clinic or if I develop a good enough rapport during their visit, I would ask if I could perhaps interview them or if they know anyone that is a patient of the clinic that may be interested in participating in an interview.
Description of Methods: I plan to use participant observation, individual and group interviews and photography to gather information regarding the capitals and answer the research questions.
As a volunteer in the clinic I will be able to make participant observations. I want to record in a daily field journal all the information and situations I encounter that relate to these capitals. While I’m volunteering at the health center or interacting with the community, I will make participant observations and notes on things relating to the capitals and if need be, note how I could learn more—through more observation or with an interview. As a volunteer I’ll experience some of the stresses of working in the clinic, see the interaction between patients and staff or staff and administration. I’ll see the resources that the clinic has and be able to explore and learn about the built aspects of the clinic. I will learn a lot about the capitals just with participant observation. Beyond volunteering at the clinic, I hope to learn about cultural, social, and political events I would be free to observe and as they relate to the clinic or to my research, I’ll take notes on the experiences and what aspects may relate to my research. I believe that recording my own thoughts on the audio recorder will help me recall information better than with written notes alone. This will allow me to describe what I see or experience without being as obtrusive as if I used a video recorder or camera to record what I see and experience.
The interviews I conduct will be semi-formal in nature with an emphasis on the topic or capital they understand or deal with in day to day life. While I’m unsure about the topic and questions for each interview as well as unsure about my skills as an interviewer, I will rely on readings in the Preparation course and make sure I prepare questions and possible topic for interviews beforehand; some of the questions or topics I’ll consider are listed later in this paper.
I’ll use this in interviews with people in the community to increase my understanding of the complex aspects of the community’s culture and multiple social networks. I hope to find out the attitudes and relations that the clinic has with people involved in each capital, including administration, staff and patients of the health center, political figures and traditional and cultural figures in the community. I would like to learn how local leaders and community members identify the role these capitals relate to the health center. In the case of patients who I recruit for interviews, I will focus the conversation we have on their general experiences with the clinic as it applies to the capitals, including interactions with staff members, mode of travel to health center, or challenges they experience in accessing health care. I will request at the beginning of the interview or during recruitment that patients avoid disclosing details about their reason for associating with the health center.
Another type of interview I will conduct is group interviews. The goal for the informal, semi-structured group interviews is to learn from groups of the health center staff the things that are of principle importance to the clinic, as well as a means of identifying different concerns or challenges the staff has seen the clinic experience within the Wiamoase community, as the participants reason together to answer questions in a relaxed, casual environment. Though I don’t consider these group interviews the crux of my study and don’t yet know how I will facilitate them within the staff, it will be the most effective way to begin my research within the community and would be a useful resource when considering who in the community I should include in my collection of interviews. If I’m unable to get a group of staff or community members together for a group interview, I plan to begin in individual interviews or public places to ask questions or ask people to help me with a PRA activity. When I move to another social situation or interview, I can pull out the same activity and add new insights from the informant. I also plan to hold group interviews two or three times during the study for subjects that I want explore and want to get a general understanding about. I don’t have a complete framework for my interviews but I plan to ask questions like the examples in Appendix F and use PRA methods for each capital.
My approach to my observations and interview topics are focused on the seven capitals. What I hope to explore within these capitals are these questions and topics:
• Natural Capital: Where are the most incidences of disease occurring? What diseases are prevalent for the area? How does the climate, seasonal shifts in temperature and precipitation, and climate type influence the disease or health in the community? How much time does it take to travel to (Name of Institution)? Dry season ____ Wet season___? What are the water sources, water quality and quantity in the community?
• Cultural Capital (include traditional and religious aspects): Do values and heritage recognition and celebration affect the health center? What is the nutritional value of the foods they prefer to consume? What is the historical context of health in this community? How were illnesses or diseases treated traditionally? How prevalent are these practices presently? What are the basic Ashanti traditions regarding birth, death, marriage and family and how does this affect health and access to health? How open is the culture of the community to change?
• Human Capital: What are the general demographic statistics of the staff in the clinic? Where do they come from, what are their ages, what education have they received and from where? How is the staff perceived by the patients? What demands and stress does the staff feel? What demands or stress do the patients feel from interaction with the staff? How do the patients view the qualifications of the staff? What are the personalities of the staff and how does that influence the health center atmosphere? What is the general level of health in the community? What is the level of education in the community? Use of language: How do patients and staff refer to each other? Is it in a dehumanizing way that effects the relationships between them (Patrick’s paper)?
• Social Capital: What forms of reciprocity are available or expected in the community? For the health center? Is there any form of reciprocity beyond money payment? What networks or groups within the community is the health center associated with? Do these networks influence who comes to the health center? Does it affect the community support the health center receives? Do the health centers or the community share a common view or goal for health care? Other than the services offered by this health center now, are there any other services that should be developed here that the community needs? Is the ability of the health center to meet the needs of the community increasing since it was established, unchanged since it was established, or decreasing since it was established? What other health services does your community have? (Include a list health service facilities)
• Political Capital: What is the relationship that the clinic has with the local leaders (political and traditional)? Does the government garner resources for the health center? How involved is the local government in health? Was the government involved in the selection of this area as a site for a Salvation Army Health center? What property rights does the health center have?
• Financial Capital: Where does the bulk of the financial support for the clinic come from? What fraction of the health center’s financial capital comes from the work they do? Are they financially self-sustaining? Are there services a burden for potential patients? Are there local donations the health center receives? What fraction of clinic expenses comes from resources and supplies spending? Staff wages? Are there things they can’t afford but have a demand or need for? Does the clinic have a “cash and carry” system of healthcare that influences how patients receive healthcare (Patrick)? Is there a correlation between hospital bills and patient bills or are the bills normalized? It is difficult to quantify medical care services in terms of money, how does the health center determine the price of services?
• Built Capital: What transportation is available for the patients to reach the health center? What power and telecommunications abilities does the health center have? How functional and serviceable is the building? Does the health center have excess capacity, or is the size about right, or is it too small? Are the health center buildings in good condition or poor condition? Are its patients mainly from local neighborhoods, from communities close by, or from very distant communities? What other facilities are needed to help treat the patients? Is there scheduled (bus, rail, boat, air) service to the Health Center? If yes, what, and how often (daily weekly)? In case of emergency or major illness, where to people generally go to get help? Name of Institution_______________. Location___________________. How do people usually get there? _____________ In case of emergency, is transportation available? (Always, sometimes, rarely) What is the state of the community water and sewage system?
If during the course of an interview, the participant(s) feel uncomfortable answering a question, they are welcome to refuse an answer or decline to participate at any point. While conducting these interviews, I would like to record the information with an audio tape recorder and the information presented in these recorded sessions will then be transcribed. These recordings will include the following information: the date and time of the recording, the summary of its contents, the name of the person being interviewed or the situation I’m recording my personal observations about, and any further comments and/or cross references (to my field notes or to other articles, for example) if applicable.
An important part of the interview process will be the location I can conduct interviews. When I arrive in Wiamoase, I’ll be trying to identify a good place within the community where I can conduct interviews. I’ll conduct the interviews primarily in people’s homes or offices, but if those aren’t areas that aren’t uncomfortable or convenient for the interviewee, I’ll strive to find a place within the community where I can conduct interviews. I will not conduct interviews in my place of residence.
As a part of the requirements for my course contract with Joan Dixon, I will compile the information I gather from my field notes, my observations, interview methods, any paperwork from using PRA methods, and interview notes into a book for my final project.
Data Analysis The focus question of this study is “How do different factors (related to capitals) affect the ability of people in Wiamoase to access health care?” The information I collect from observation and interviews will be organized according to capital, and any information that was identified as making health care access easy or making it difficult will be qualitatively labeled that way. The capitals that contain high incidences of “difficult” will be identified as areas that the health center and community could focus improvement efforts. The capitals that contain high incidences of “easy” could be identified as strengths of the health center and community in providing equitable access to health care.
