Little legs

Posted by Linda Penn

I was pleased that the train arrived to take me to Middlesbrough on a freezing January morning, although not so pleased that it was the cold train (heating in this train hasn’t worked for months). By the time I got to Middlesbrough station I was frozen through. Claire picked me up and took me to an annex at the back of what used to be St Cuthbert’s church. In this very cold and rather dark annex was a ‘community gym’ and I was there to interview South Asian women about their physical activity, as part of the evaluation of our preventive intervention feasibility study. By then I was so cold I would have preferred to tramp the treadmill to warm up or maybe even indulge in beginners’ Zumba. However, when the women started talking I forgot to be cold. Qualitative research can be such joy.

St. Cuthbert's Church, Middlesbrough, 1965

St Cuthbert’s church used to be near my uncle’s butchers shop, until the planners bulldozed the community to drive a road through the heart of the town and move people out to a concrete desert. I didn’t know, until my cousin told me recently, but they had apparently sold halal chicken from this shop. So there must have been a Muslim community in Middlesbrough for some time.

My great aunt Minnie’s sweet shop was also somewhere nearby St Cuthbert’s. I think she ran the shop from the front room of one of the little terraced ‘slum’ houses. This house too has long since been reduced to rubble. I only remember going there once and I was very young. Minnie was too old then to keep shop and my sister and I had been warned that Minnie had ‘little legs’. We were not to ask or comment. In fact, we should just pretend we had not noticed. The legs were not at all obvious when we arrived as she was sat in her big chair by the fire, with a rug over her knees. However after a while she got up to fetch the coal from the back kitchen. When she got up she was walking on her knees – the little legs. It was a shock, which must be why I remember. Nevertheless Minnie managed to negotiate down the stone step into the back kitchen to fetch the coal and obviously back up the step with the bucket of coal. I remember watching her. I am sure someone would have offered to go and get the coal for her, but she must have refused with such determination that no-one dared interfere. 

St. Cuthbert's Church, Middlesbrough, 2008

Not until years later did I appreciate that Minnie’s little legs were as a result of diabetes related amputations. That was my first introduction to the nasty, progressive and debilitating disease that is diabetes. It was pure serendipity that this January I was back almost where I started and the prevention message is the same. Although I hope the prosthetics have improved.

Seeing is believing: exploring qualitative methods beyond text and talk

Posted by Shelina Visram (with Ann Crossland)

In the run up to the recent UKCRC Public Health Research Centres of Excellence meeting, I received an email asking for volunteers to help organise and deliver workshops. One of the suggested topics – ‘The use of novel qualitative methods in evaluation research’ – immediately caught my eye. I’ve been involved in a number of evaluations and most have relied on qualitative methods. So I put myself forward and was glad to hear Professor Ann Crosland had volunteered too. We decided Ann should do the bits on using commonplace methods in novel ways and I’d do the bits on visual methods. Then we went our separate ways to work on the content.

That’s when I stopped and thought: how much do I really know about visual methods? Yes, I’ve used them in a number of projects but I’m certainly no expert. I wondered who would attend this workshop. Would they be expecting to explore the philosophy of creative methods? Should I be using words like epistemology and ontology? Or could I get away with showing cute pictures drawn by small children? I decided the most sensible approach would be to hedge my bets and do a bit of both (without getting bogged down by philosophy).

Picture drawn by a 7-year-old when asked “What things affect your health?” during the evaluation of a weight management programme 

Here comes the science… Qualitative research relies heavily on the things people write or say. If you’re a positivist, you might ask how we know whether this information is ‘true’, i.e. does it accurately reflect the ‘real world’? We interpretivists tend not to worry about those things and instead accept the existence of multiple realities and therefore multiple versions of the ‘truth’. However, we still assume that what people write or say is a reliable account of their truth. Yet we know that people have different capacities and motives for sharing information. During interviews or focus groups, participants are telling particular stories in a particular social context. To what extent can we use these stories to draw interpretations about their lives outside of that context?*

This is part of the rationale for using visual methods. We acknowledge that the information people provide verbally or in writing is only ever partial and cannot be taken at face value. Visual methods give us an alternative means to examine their beliefs, attitudes, experiences and ideas about themselves. These methods are particularly useful in exploring the routine of daily life that tends to go unnoticed. For example, how many of us could describe our journey to work in any great detail? Yet if we were asked to draw, map, photograph or film our travels, we would undoubtedly provide a far richer picture of the same journey. Other examples of creative methods include spider diagrams, clay modelling, body mapping, and something called Lego Serious Play which I am desperate to try (but maybe with Fuzzy Felts – remember them?).

Advantages of using visual methods include the fact that they are interactive, encourage free expression, and often generate unexpected findings. They are also inclusive, in that they don’t require participants to be especially articulate in speaking or writing in English. I’ve used drawing in a project involving children from 4-years-old and this helped to give them a ‘voice’ in evaluating a service. Challenges include the potential to generate vast amounts of data that can be difficult to interpret, although visual methods are generally used alongside interviews and focus groups. This helps to engage participants in the process of interpretation. There are also ethical issues to consider; for example, consent is required if others appear in photos or videos.

It can take a lot of time, energy and resources to use creative methods in any research or evaluation activity. But I would argue that they represent one way of overcoming some of the criticisms about the validity and anecdotal nature of qualitative research. And they’re fun too.


*For an in-depth discussion of this argument, read this book.

Let’s get out of the office and see what’s really happening

Posted by Dorothy Newbury-Birch

When putting bids together for research we have to think carefully about how a project can happen ‘in the field’. We look at the evidence to date and often ask people who are working in said 'field' for advice on how things can work. But is this enough?

I would argue not always – for us to really understand what we are asking people who take part in research to do, we need to get out there and look for ourselves how things could work in practice. For example if I am working on a project where I would like ambulance staff to screen patients for alcohol use disorders how can I really know what normal practice is like without observing it for myself?

Hanging out with an ambulance crew - good fun, good research

I have, to date, carried out observational work for these very reasons, in an Accident and Emergency Department (AED) on black Friday - the Friday before Christmas. I quickly realised that asking AED staff to ask lots of questions about alcohol wasn’t really a good idea. In fact, just getting a cup of coffee that night was barely feasible. However, using a shorter questionnaire, perhaps at the triage stage, might be.

I also spent two weekends with an ambulance crew and learned that paramedics make small talk in the back of the ambulance with a lot of patients whilst they are being transferred to the AED. This makes it an ideal opportunity for research to take place. I also realised that quite a few people who paramedics are called to see, are not transferred to hospital. The paramedics were frustrated about not being able to do anything with these people (another opportunity for research).

I spent a night with the maxillofacial team in AED where I learned that they are slightly separate to the core AED staff and in the main do have more time (yet another opportunity for research). Finally I spent a couple of nights on a project with police and paramedics where I’m not sure what I learned, but it was fun.

Of course, there are loopholes to get through in order to do observational work like this, forms to be filled in (including risk assessments). I am always honest about my reasons for doing the work with the people I’m working with and this is important for good relationships. I always, always take goodies for the team (blueberry muffins, cherry bakewells).

Ultimately I think this observational work means we end up with better research. And it's really, really, really good fun. So give it a try.

Routine Secondary Data

Posted by Lynne Forrest

We all know what a nightmare it is trying to recruit participants for research studies. So if you only have to get hold of some routine data that’s just sitting there, well, that’s going to be much simpler, isn’t it? You’d think....

The plan for my PhD was to look at inequalities in cancer care by linking cancer registry and Hospital Episode Statistics data for lung cancer, and also linking to audit data. This is routine data that has already been collected and so I naively assumed it was just a case of getting ethical approval to access the data, finding someone to cobble the data together and off we go. I wrote an optimistic project timetable where I would get my hands on the data about seven months into the PhD. Eighteen months in I’ve finally got hold of some unlinked data and I’m still waiting for the rest.


I don't work for News International, so what's the problem? Photo: Christian Sinibaldi

So, what went wrong?

I think my first mistake was assuming that just because the data was there it would be easy to get hold of. There are a lot of hoops you have to jump through first.

I thought that what I wanted to do was simple but it turns out that it’s not. This is apparently the most complicated linkage that the cancer registry has undertaken and the bottom line was, nobody wanted to do it. I spend a lot of time begging people to speak to me and basically being fobbed off, in the nicest possible way. Luckily I eventually found a newly-joined analyst who was willing to give it a go. I’m not sure that she’s thanking me now...

Issues then arose of whether the data I wanted might be identifiable. Variables such as date of birth and death are classed as identifiable and individual records are ‘potentially-identifiable’, even if they don’t include identifiable information (which is an excellent catch 22 – they are identifiable even though they are not identifiable...)!

Finally it seemed like it was all coming together. I’d agreed with the registry that they would supply me with anonymised data containing ages rather than dates, I’d made it through ethics, and I’d got some data. But, on checking, not exactly the data I wanted. So, currently I am discussing with the registry how it will be possible for me to calculate survival time if they won’t allow me to have data on the number of days from diagnosis to death. Survival from lung cancer is short and rounding to the nearest year isn’t going to identify survival differences with any degree of accuracy.

The sticking point is that although they are not supplying me with date of death I could theoretically work it out from this information and that makes the data (aaagh!) ‘identifiable’. However, as I don’t have an NHS number, date of birth, or place of death, I don’t know how I would identify anyone from the 140,000 records I have. Plus I’m a researcher, not a News International journalist, and I’m not interested in anyone individually, so I’m not going to attempt to do this.

Can’t I just sign something to that effect and have the data I need please?

A room of one's own

Posted by Stephanie Clutterbuck

I have never read "A room of one's own". But I thought it made a snappy title for a blog post so I did what any self-respecting early career researcher does when she wants to make sure she is not talking complete nonsense- I Wikipedia-ed it. Turns out it fits quite nicely. You see Virginia Woolf believed that "a woman must have money and a room of her own if she is to write fiction". And although I have no interest in writing fiction I can see her point, a woman must have participants and a room of her own if she is to do science.


Virginia Woolf, by Frederico Novaro

There I was, March 2012, a bright-eyed PhD student confident in my experimental design, armed only with some predictions and a dream. Against my better judgment I believed that data collection in schools would be easy and as long as I asked nicely for ‘a quiet room’ my wish would be granted leaving my data collection to roll merrily along, untainted by extraneous factors.

Fast-forward two months, seven schools and 200 participants later and I have learned an invaluable lesson: schools have very different definitions of ‘a quiet room’.

At my first school I was shown to an open corridor where I was told I would run my experiment. Admittedly, I had to suppress my inner toddler from stamping her feet and screaming ‘This is NOT a quiet room!!’, but I made do. And in fact it would have worked well if the corridor wasn’t simultaneously being used as a makeshift studio for yearbook photos. And then as a meeting place for all the Year 5 boys to earnestly discuss the moral implications of stealing the Year 6’s football during break. To be fair it was a lively debate and I could see their point, why should the older boys get the ball - isn’t that ageism?

Still, data collection continues to roll along in various schools and I have become adept at managing my inner meltdowns regarding the unreality of tightly controlled experimental conditions outside of the lab. I was able to force a smile when a teacher barged into my quiet room (which happened to also be a kitchen) and rattled the contents of every drawer and cupboard in search of a knife to cut cake. And I have learned to tune out repeated renditions of ‘Kung Fu Fighting’ and ‘Heart and Soul’ sung by jubilant five year olds in nearby music rooms.

Fortunately, for my sanity, I feel data collection enlightenment is within reach. The other day I unflinchingly accepted that there was nothing I could do about the man in muddy overalls wielding a shovel and walking through my quiet room. Twice.