Emily Namey

How Many Focus Groups Are Enough? Building an Evidence Base for Nonprobability Sample Sizes:

Few empirical studies exist to guide researchers in determining the number of focus groups necessary for a research study. The analyses described here provide foundational evidence to help researchers in this regard. We conducted a thematic analysis of 40 focus groups on health-seeking behaviors of African American men in Durham, North Carolina. Our analyses revealed that more than 80% of all themes were discoverable within two to three focus groups, and 90% were discoverable within three to six focus groups. Three focus groups were also enough to identify all of the most prevalent themes within the data set. These empirically based findings suggest focus group sample sizes that differ from many of the “rule of thumb” recommendations in the existing literature. We discuss the relative generalizability of our findings to other study contexts, and we highlight some methodological questions about adequate sample sizes for focus group research.

Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces

OBJECTIVE to examine factors that affect retention of public sector midwives throughout their career in Afghanistan. DESIGN qualitative assessment using semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). SETTING health clinics in eight provinces in Afghanistan, midwifery education schools in three provinces, and stakeholder organisations in Kabul. PARTICIPANTS purposively sampled midwifery profession stakeholders in Kabul (n=14 IDIs); purposively selected community midwifery students in Kabul (n=3 FGDs), Parwan (n=1 FGD) and Wardak (n=1 FGD) provinces (six participants per FGD); public sector midwives, health facility managers, and community health workers from randomly selected clinics in eight provinces (n=48 IDIs); midwives who had left the public sector midwifery service (n=5 IDIs). MEASUREMENTS AND FINDINGS several factors affect a midwife throughout her career in the public sector, including her selection as a trainee, the training itself, deployment to her pre-assigned post, and working in clinics. Overall, appropriate selection is the key to ensuring deployment and retention later on in a midwifes career. Other factors that affect retention of midwives include civil security concerns in rural areas, support of family and community, salary levels, professional development opportunities and workplace support, and inefficient human resources planning in the public sector. KEY CONCLUSIONS Factors affecting midwife retention are linked to problems within the community midwifery education (CME) programme and those reflecting the wider Afghan context. Civil insecurity and traditional attitudes towards women were major factors identified that negatively affect midwifery retention. IMPLICATIONS FOR PRACTICE Factors such as civil insecurity and traditional attitudes towards women require a multisectoral response and innovative strategies to reduce their impact. However, factors inherent to midwife career development also impact retention and may be more readily modified.

Evaluating Bang for the Buck A Cost-Effectiveness Comparison Between Individual Interviews and Focus Groups Based on Thematic Saturation Levels

Evaluators often use qualitative research methods, yet there is little evidence on the comparative cost-effectiveness of the two most commonly employed qualitative methods—in-depth interviews (IDIs) and focus groups (FGs). We performed an inductive thematic analysis of data from 40 IDIs and 40 FGs on the health-seeking behaviors of African American men (N = 350) in Durham, North Carolina. We used a bootstrap simulation to generate 10,000 random samples from each data set and calculated the number of data collection events necessary to reach different levels of thematic saturation. The median number of data collection events required to reach 80% and 90% saturation was 8 and 16, respectively, for IDIs and 3 and 5 for FGs. Interviews took longer but were more cost-effective at both levels. At the median, IDIs cost 20–36% less to reach thematic saturation. Evaluators can consider these empirically based cost-effectiveness data when selecting a qualitative data collection method.

Comparing focus groups and individual interviews: findings from a randomized study

Abstract Qualitative researchers often have to decide whether to collect data using focus groups or individual interviews. We systematically compare these two methods on their ability to generate two types of information: unique items in a brainstorming task and personally sensitive disclosures. Our study sample consisted of 350 African-American men living in Durham, North Carolina. Participants were randomized into either a focus group arm or individual interview arm, and were asked the same open-ended questions about their health-care seeking behavior. For the item-generating task, we compared data at two levels of analysis – the event and the individual. At the event level, focus groups and individual interviews generated similar numbers of unique items in a free-listing task. When compared on a per-person basis, however, individual interviews were more effective at generating a broad range of items. We also compared the number of data collection events in which personal, sensitive information was disclosed. We found that several types of sensitive and personal disclosures were more likely in a focus group setting, and that some sensitive themes only occurred in the focus group context. No sensitive themes emerged exclusively, or more often in, an individual interview context. Researchers may use these findings to help align their choice of qualitative data collection method with research objectives.

Public health research methods

1: Introduction to Public Health Research Methods - Greg Guest PART I: Planning and Preparing for Research 2: Designing Research - Heidi Reynolds, Greg Guest 3. Research Ethics and Working with Institutional Review Boards - Amy Corneli, David Borasky 4. Cultivating Stakeholder Involvement in Public Health Research - Dazon Dixon Diallo, Paula Frew In Focus: Community-Based Participatory Research - Karen Hacker and Greg Guest PART II. TRADITIONAL EPIDEMIOLOGIC METHODS & DESIGNS 5. Public Health Surveillance: From Data to Action - Donna Stroup, Steven Thacker 6. Outbreak Investigation - Douglas Hamilton 7. Cohort and Case Control Studies - Lee Warner, Deborah Dee 8. Designing Randomized Controlled Trials - Theresa Gamble, Danielle Haley, Niru Sista, Raymond Buck PART III. STRUCTURAL AND OPERATIONAL RESEARCH 9. Using Secondary Data - Sarah Boslaugh 10. Economics of Population Health - Emma McIntosh, Cam Donaldson, Lyndal Bond, Kenny Lawson In Focus: Cost Analysis for Interventions - Rick Homan 11. Health Services Research - Heidi Reynolds 12. Survey Design and Implementation - Jeanne Bertolli, Kathy Hageman, Travis Sanchez, Andrea Kim 13. Scale Development and Validation - Glenn Gamst, Lawrence S. Meyers, Holly McClain Burke, A. J. Guarino 14. Social Network Analysis. Methods and Applications in Public Health - Elizabeth Costenbader, Thomas Valente 15. Qualitative Research Methods - Emily Namey, Robert Trotter II 16. Randomized Controlled Trials for Psychosocial Interventions - Phyllis Solomon, Mary Cavanaugh PART IV. CROSS-CUTTING METHODS AND APPROACHES 17. Sampling: The Foundation of Good Research - Johnnie Daniel 18. Statistical Methods in Public Health Research - Mark Weaver 19. Mixed Methods Research - Greg Guest, Paul Fleming In Focus: Using Vignettes in Public Health Research - Paul Fleming, Michael Stalker 20. Geographic Information Systems (GIS) in Public Health - Candace Nykiforuk 21. Public Health 2.0. Fresh Approaches to Old Problems - Hans Ossebaard and Lisette van Gemert-Pijnen In Focus: Mobile and Digital Data Collection in the Field - Mitesh Thakkar, Nikhil Wilmink, Rachna Nag Chowdhuri, Sruthi Chandrasekaran PART V. APPLYING RESEARCH FINDINGS 22. Enhancing Research Utilization - Jeffery Peterson, Angie Funaiole 23. Implementation Science. Identifying the Path from Innovation to Impact - Temina Madon APPENDIX 1. Theories and Models in Public Health Research

When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling

Abstract Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their ‘normal’ daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants’ reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.

Evidence-Based Strategies for Shortening Informed Consent Forms in Clinical Research

Long informed consent forms (ICFs) remain commonplace, yet they can negatively affect potential participants’ understanding of clinical research. We aimed to build consensus among six groups of key stakeholders on advancing the use of shorter ICFs in clinical research. Partnering with the HIV Prevention Trials Network (HPTN), we used a modified Delphi process with semistructured interviews and online surveys. Concerns about redundancy of information were common. Respondents supported three strategies for reducing ICF length: (a) 91% agreed or strongly agreed with grouping study procedures by frequency, (b) 91% were comfortable or very comfortable with placing supplemental information into appendices, and (c) 93% agreed or strongly agreed with listing duplicate side effects only once. Implementing these strategies will facilitate adoption of the proposed changes to U.S. regulations on ICF length, should they be enacted.

Preparing for the Rollout of Pre-Exposure Prophylaxis (PrEP): A Vignette Survey to Identify Intended Sexual Behaviors among Women in Kenya and South Africa if Using PrEP

Introduction Several clinical trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV risk. One concern with introducing PrEP is whether users will engage in riskier sexual behaviors. Methods We assessed the effect that PrEP may have on sexual risk behaviors by administering a survey to 799 women in Bondo, Kenya, and Pretoria, South Africa. Participants were asked about their sexual behavior intentions twice — once as if they were taking PrEP and once as if they were not taking PrEP — within four risk situations (vignettes). They responded using a 5-point ordinal scale. We used a series of linear mixed effects models with an unstructured residual covariance matrix to estimate the between- and within-subject differences in the mean likelihood of engaging in risky sexual behavior across the PrEP and non-PrEP contexts. We also calculated the total percentage of participants who reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP, by vignette. Results We found statistically significant differences in the mean likelihood of engaging in risky sexual behavior with the between-subject comparison (-0.17, p < 0.01) and with the within-subject comparison (-0.31, p < 0.001). Depending on the vignette, 27% to 40% of participants reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP. Conclusions Our findings indicate that modest increases in risky sexual behavior could occur with PrEP. Although responses from the majority of participants suggest they would not be more likely to engage in risky sexual behavior if they took PrEP, a substantial proportion might. Programs rolling out PrEP should be prepared to assist similar women in making informed choices about reducing their risk of HIV and about their sexual health beyond HIV prevention.

Institutional review boards' use and understanding of certificates of confidentiality.

Certificates of Confidentiality, issued by agencies of the U.S. government, are regarded as an important tool for meeting ethical and legal obligations to safeguard research participants’ privacy and confidentiality. By shielding against forced disclosure of identifying data, Certificates are intended to facilitate research on sensitive topics critical to the public’s health. Although Certificates are potentially applicable to an extensive array of research, their full legal effect is unclear, and little is known about stakeholders’ views of the protections they provide. To begin addressing this challenge, we conducted a national survey of institutional review board (IRB) chairs, followed by telephone interviews with selected chairs, to learn more about their familiarity with and opinions about Certificates; their institutions’ use of Certificates; policies and practices concerning when Certificates are required or recommended; and the role Certificates play in assessments of research risk. Overall, our results suggest uncertainty about Certificates among IRB chairs. On most objective knowledge questions, most respondents chose the incorrect answer or ‘unsure’. Among chairs who reported more familiarity with Certificates, composite opinion scores calculated based on five survey questions were evenly distributed among positive, neutral/middle, and negative views. Further, respondents expressed a variety of ideas about the appropriate use of Certificates, what they are intended to protect, and their effect on research risk. Nevertheless, chairs who participated in our study commonly viewed Certificates as a potentially valuable tool, frequently describing them as an ‘extra layer’ of protection. These findings lead to several practical observations concerning the need for more stakeholder education about Certificates, consideration of Certificates for a broader range of studies, the importance of remaining vigilant and using all tools available to protect participants’ confidentiality, and the need for further empirical investigation of Certificates’ effect on researchers and research participants.

Understanding the financial lives of female sex workers in Abidjan, Côte d’Ivoire: implications for economic strengthening interventions for HIV prevention

ABSTRACT Many women’s decisions about whether and how to participate in sex work are driven by financial considerations. Despite the recognized importance of economic factors in HIV risk among female sex workers (FSWs), many HIV prevention programs focus narrowly on sexual risk behaviors. We collected data on the financial practices of FSWs in Abidjan, Côte d’Ivoire, to better inform economic strengthening programs for HIV risk reduction with this population. We conducted “walk-along” participant observations (N = 74) during FSWs’ daily non-working routines and analyzed resultant notes using qualitative thematic analysis. We used a financial diary methodology to collect detailed quantitative data on income, spending, savings and lending from a sub-sample of participants (n = 33) over six weeks; these data were analyzed using descriptive statistics. All women in our sample reported sex work as their primary source of earned income. Median weekly income was roughly US