Appendix F. MISP Evaluation Team Training Sample Presentation
Process Evaluation of
MISP Implementation
in Kathmandu and
Sindhupalchok, Nepal
Training: Focus Group Discussion (FGD)
September 10-12, 2015
Samira Sami, MPH
DrPH Candidate
Johns Hopkins University
Anna Myers, MPH
Research Manager
Women’s Refugee Commission
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1
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Agenda
•
Day 1: Training
– Introductions
– Staff roles and responsibilities
– Overview of the MISP
– Overview of the evaluation methodology
– Ethical issues and safety protocols
– Overview of focus group discussions (FGDs)
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Agenda (2)
•
Day 2: Training
– Introduction to FGD Tools
– Practice, practice, practice
•
Day 3: Pilot
– Conduct one male and female FGD
– Practice translation/transcription
– Debrief
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Introductions
•
•
•
•
What is your name?
Where are you from?
What are your favorite activities to do?
What is your research experience?
– Experience in qualitative research
– Experience in reproductive health research or
other work
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Staff Roles and Responsibilities
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Structure of Evaluation Team
Site 1: Kathmandu
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
Site 2: Sindhupalchok
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
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Roles/Responsibilities of Teams
Roles
Facilitator
Notetakers
Interpreter
Responsibilities
Timeliness
Respect
Be prepared
Team player
Ask questions!
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Timeline of Activities
Sunday
Monday
Tuesday Wednesday
Thursday
Friday
Saturday
6
7
8
9
10
Training
11
Training
12
Pilot
13
14
Data Collection
Day #1
15
Data
Collection
Day #2
16
Data Collection
Day #3
17
Data Collection
Day #4
18
Data Collection
Day #5
19
Debrief Day
20
21
Debrief with
stakeholders
22
23
24
25
26
Timeline
9
Timeline
10
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Communication Protocol
Security Issues
Administration
Hours and lateness
Housekeeping issues
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Planning FGD Schedule and
Participant Recruitment
List of health workers
How to recruit participants and informed consent
Selecting the right environment/setting
Scheduling dates/times for your FGDs
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QUESTIONS?
13
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Overview of the MISP
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Reproductive Health in Crisis
Settings
• WHY do we need to pay attention to RH in a crisis?
• 60% of preventable maternal deaths & 53% of child
deaths occur during crisis
• 4% of population pregnant at any time:
– 15% of pregnant women will need emergency obstetric care
– 9-15% of newborns will need live-saving emergency care
• Consequences of crisis can elevate mortality and sexual
violence
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Reproductive Health in Crisis
Settings (2)
• How does crisis worsen reproductive health?
–
–
–
–
–
–
Destruction of health facilities
Lack of trained staff
Health facilities overwhelmed
Breakdown of social structures, families
Lack of supplies
No access (displacement, security, cultural restrictions,
knowledge/attitudes towards HC, economics)
– Targeted and opportunistic sexual violence
– Sexual exploitation
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What is the Minimum Initial
Service Package (MISP) for
Reproductive Health?
• Minimum:
– Ensure basic, limited reproductive health services
• Initial:
– For use in emergencies, without site-specific needs
assessment
• Service:
– Health care for the population
• Package:
– Activities, supplies, coordination and planning
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Objective 1: Coordinating
implementation of MISP
priority RH services
Ensure the health sector/cluster
identifies an organization to lead
implementation of the MISP.
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Objective 2: Preventing and managing the
consequences of sexual violence
• Putting in place measures to protect
affected populations from sexual
violence
• Making clinical care available for
survivors of rape
• Ensuring the community is aware of
the available clinical services
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Objective 3: Reducing the spread of HIV
• Ensuring safe and rational blood
transfusions
• Enforcing respect for standard
precautions
• Guaranteeing the availability of
free condoms
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Objective 4: Preventing maternal and newborn death
and disability
• Ensuring availability and
accessibility of EmOC and newborn
care services at health facilities
and referral hospitals
• Establishing a referral system
• Providing clean delivery kits
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Objective 5: Planning for
Comprehensive RH Services
•Collecting existing background data
•Identifying suitable sites for
future RH service delivery
•Assessing staff capacity
•Ordering equipment and supplies
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Additional MISP Priorities
•Family Planning
•Sexually Transmitted Infections
•Prevention of Mother-to-Child
Transmission of HIV/AIDS
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QUESTIONS?
25
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Overview of Evaluation
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Evaluation Methodology
• Case study design
– Kathmandu
– Sindhupalchok
• Purposive sampling
• Population
– Program staff
– Health workers
– Community
• Methods:
– Key informant interviews
– Health facility assessments
– Focus group discussions
Method
Sampling plan
Data collection
strategy
Key informant
interviews
Program managers
and staff
• Semi-structured
interviews
Health facility
assessments
25 health facilities
• Structured
questionnaire
Focus group
discussions
32 focus groups
(male and female)
• Open ended
questions
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Evaluation of the Implementation of the MISP for RH
among Crisis-Affected Persons in Kathmandu and
Sindhupalchok, Nepal
•
Purpose of FGDs
– To qualitatively assess the extent that the MISP has been implemented
in Kathmandu and Sindhupalchok since the earthquake
•
FGD Objectives
1. To assess the extent that RH services are available and accessible
2. To explore how resources (human and material) relevant to the MISP
were allocated, mobilized, and delivered by agencies in the
humanitarian response
3. To explore awareness about and use of RH services by the crisisaffected population
4. To explore the factors that influence the implementation of the MISP
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Focus Group Discussions
•
•
Purpose: To understand the knowledge, attitudes, and access of RH
services among the crisis-affected population
Group composition: no more than 10 participants per group
Site 1 – Kathmandu
Site 2 – Sindhupalchowk
TOTAL
No. of FGDs No. of FGDs No. of FGDs
near health far from
near health
facilities
health
facilities
facilities
No. of FGDs No. of FGDs
far from
across all
health
sites
facilities
2
2
2
2
8
Boys aged 15-24 years 2
2
2
2
8
Women aged 25-49
years
Men aged 25-49 years
2
2
2
2
8
2
2
2
2
8
Age-Gender Group
Girls aged 15-24 years
32
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Evaluation Collaborators
Evaluation Team
Women’s Refugee Commission
Boston University School of Public Health
Johns Hopkins Bloomberg School of Public Health
RIDA research staff
Evaluation Partners
Department of Health (DOH) Nepal
United Nations Population Fund (UNFPA) Nepal
FPAN - SPRINT (Sexual and Reproductive Health Programme in
Crisis and Post-Crisis Situations)
Reproductive Health Sub-Cluster in Nepal
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Evaluation Outcomes
• Share findings with evaluation partners to inform the
development of program and policy recommendations
• Improve reproductive health services for people affected by
the earthquake in Nepal
• Disseminate final report for local and international learning
• Inform future emergencies by ensuring quality RH services
are provided to affected populations in similar contexts
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QUESTIONS?
33
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Lunch!
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Ethical Issues and Safety Protocols
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Principles of Ethical Research
• Respect integrity & minimize harm
• Informed consent
• Confidentiality
• Privacy
• Secure handling of data
• Sharing results with relevant stakeholders
• Understand the referral pathway for gender based violence
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Elements of Consent
• * If non-literate, read slowly in appropriate language and
ask for questions
• Introduction
•
•
•
•
•
•
Purpose of Study
Procedures
Risks & benefits
Questions or Concerns
Confidentiality
Voluntary Participation
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Practice: Informed Consent
• Read out loud
• Identify consent elements:
– Purpose of Study
– Procedures
– Risks and benefits
– Questions or concerns
– Confidentiality
– Voluntary Participation
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Eligible FGD Participants
• 18 and older → regular consent
• 15 to 17 years: must meet one of these
– Ever Married
– Pregnant
– Parent of a child
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Referral Pathway for Gender Based
Violence
•
See Handout
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Overview of Focus Group
Discussions
Quantitative vs. Qualitative Research
• Qualitative:
• Attempts to
explain
• Complex, changing
( ‘fluid’)
• Describes
meanings:
• Perceptions,
knowledge, beliefs,
behaviors
• Describe variation
• Behaviors
explained in
context of what is
happening around
them
• Quantitative:
• Attempts to
measure
• Often can
quantify an event
but NOT explain
why it occurred
• Standardized so
that larger
generalizations
can be made
42
Quantitative
43
Qualitative
What happens in a
house, how is a
“home” defined, what
influences what
people do in their
houses?
44
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What is qualitative research?
•
•
•
•
•
Qualitative research is flexible.
Non-leading questions and statements are used.
Information is probed as much as possible.
Participants are treated as the expert.
The participants lead the conversation while staying
on topic.
• How and why things happen are of most interest.
• The words people use are analyzed.
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No ‘right’ or ‘wrong’ –
we are trying to
understand perceptions
46
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What is a focus group discussion?
• A group interview that emphasizes
communication among group members in
order to generate information about a
chosen topic
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Why Do Focus Groups?
•
•
•
•
•
To collect information about knowledge, behaviors, what
people think, how they think and why they think that way
To discover variety within a homogenous population
To assess areas of agreement and disagreement between
groups
To develop a consensus view on a product
To empower participants, to hear their voices
* FGDs: NOT a way to interview a number of people at
once
Roles in a FGD
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• Facilitator - conducts the group interview
– Must be able to ask and clarify a question
– Hear the response
– Determine if further clarity is needed regarding the
responses
• Notetaker- records what is being said or expressed
–
–
–
–
–
–
Responsible for ensuring detailed documentation of the FG
Back-up to recording device
Captures quotes and who is speaking
Retain specific terms or phrases in local language
Record body language and nonverbal signals of participants
Remind facilitator of issues overlooked during the
discussion
• Both positions need to work together
The Facilitator
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What are characteristics of good
facilitators?
•
•
•
•
•
•
Language and communication skills.
Familiarity with the content and structure of the activity.
Familiarity and comfort level with discussing reproductive health topics.
Ability to respect the dignity and confidentiality of participants.
Previous experience conducting focus groups or other qualitative activities.
Ability to multi-task and be flexible with adjusting questions as needed.
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Steps for Conducting a FGD
1. Prepare materials for FGD
2. Greet participants
3. Introduce yourself and the team
– Explain purpose of interview
– Describe link to local partners
4. Conduct informed consent
– Cannot promise other participants of the FGD will not
share
– Encourage FGD participants not to reveal identities
– Avoid using participant’s names during the FGD
– If participants refuse to participate, thank them for
their time and they can be excused from the group at
any time
5. Give a few brief group rules
– One speaker at a time
– No side conversations
– Everyone participating, no one dominating
How to Facilitate a FGD
(2)
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6. Move to first specific topic
– “Thank you. Let’s start with our first topic.”
– “One thing I’ve heard several people mention is _____. What else
can you say about that?” or “I’m surprised no one has mentioned
____. Does it matter or not?”
– Track connection between conversation and guide.
7. When closing, provide a summary of the
discussion
– Summarize key points of discussion with groups to
make sure important points have been captured.
– Ask if there’s anything else to add
– Don’t give out cookies/drinks until the end.
– Share the locations of existing services for
participants to access additional information and
services.
8.Prepare for debrief with research
team
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What is probing?
•
•
A way to encourage participants to say more and explain why or how to get
as much information as possible.
Types of probes are:
– Why or what questions: “What do you mean when you say…”
– Silent probe: Staying silent but supporting the participant to continue talking.
– Echo probe: Repeating the last point raised by the participant. “I see. You said that
people might talk to friends if they have a problem. Tell me more about that. What
happens then?” Be careful not to repeat something different than what was said,
as this would be leading.
– “Uh huh” probe : “oh,” “Uh-huh,” “I see”.
•
Other examples:
–
–
–
–
–
–
“Can you explain further?”
“Can you give me an example?”
“Can you say more?”
“I am not sure I understand x. Would you explain that to me?”
“How do you feel about…”
“Is there anything else?”
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What are good ways to probe?
•
•
•
•
•
•
•
“What do you mean when you say…”
“Can you explain further?”
“Can you give me an example?”
“Can you say more?”
“I am not sure I understand x. Would you explain that to me?”
“How do you feel about…”
“Is there anything else?”
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What is a leading question?
•
•
•
Leading questions are said in a way that suggests a particular answer
or implies that one answer is expected or more correct.
If leading questions are used, participants might be more likely to
agree with what we ask or think we are looking for a particular answer.
Participants are less likely to say what they really think.
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What is a leading question?
Leading questions:
• “What fears do you have when your baby’s diarrhea does
not stop?”
• “Why didn’t you take your baby to the health center for
treatment?”
• “How good was the treatment at the health center?”
Non-leading questions:
• “What do you think about when your baby’s diarrhea does
not stop?”
• “What do you do when her/his diarrhea does not stop?”
• “How do you feel about the treatment your baby got at the
health center?”
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Troubleshooting
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How should a facilitator facilitate?
•
•
•
•
•
•
•
Listen to participants and concentrate on what they are saying.
Ask questions one at a time.
Show interest and understanding.
Encourage participants to feel comfortable sharing as much information
as possible.
Remind participants to share information about the general situation
and not their personal situation.
Listen for causes and characteristics of an issue.
Be silent when silence is needed.
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What are things the facilitator should avoid?
•
•
•
•
•
•
•
•
•
•
Nodding your head, smiling, frowning or using other body movement that
can show a biased or judgmental attitude.
Giving answers to the questions and/or agreeing verbally with the
answers.
Being impatient.
Judging the answers (e.g., saying, “It is good”).
Cutting off the participants’ answers in the middle of their sentences.
Letting two or more participants talk at the same time.
Sharing your personal opinions.
Arguing with participants.
Losing control of the discussion to participants that dominate the
conversation.
Skipping any participant during the discussions.
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What are examples of participants you may
need to manage?
Challenge
Suggested Response
Talkative
Thank them for their contribution
Invite others to comment
Encourage them to make one point at a time
Asking lots of questions
Write question on flip chart and return to them
Prioritize which questions to focus on
Tired
Take a break
Anger
Acknowledge emotion or sensitivity
Steer towards sensitive issue rather than person
Shy
Encourage to contribute by calling pseudo name
Ask if agrees/disagrees with what has been shared
Personalities
Use pleasant and patient tone
Add humor, where appropriate
Full agreement
Jot down your thoughts
first, now let’s discuss
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How can different participants be managed?
•
Participants that are “the expert,” too talkative, rambling or politically
inclined:
o Use verbal and non-verbal communication, such as body motion and
eye contact.
o Repeat the topic question so that the participant understands the
topic.
• Participants that are scared, shy or confused:
o Give more attention and encouragement through using eye contact
and by being patient.
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The Notetaker
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What are characteristics of good
notetakers?
•
•
•
•
•
•
•
Excellent listening skills with the ability to listen while writing notes in an
format without slowing the tempo of the discussion unnecessarily.
Able to write verbal and non-verbal responses
Ability to listen without making comments
Ability to respect the dignity and confidentiality of respondents.
Ability to multi-task and recognize when the facilitator has altered the
sequence of the questions, which requires a strong familiarity with the
study tool.
Date must be recorded in a format that is readable, understandable, and
complete
Ability to concentrate and write notes for a period of up to 2 hours in length.
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Expectations of the Notetakers
•
•
•
•
Assign speaker identifiers and note who says what
Retain specific terms or phrases in local language
Record body language and nonverbal signals of participants
Remind facilitator of issues overlooked during the discussion
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How to Record a FGD
1.
2.
3.
4.
5.
6.
7.
Prepare the audio recorder and environment for the discussions
Document the ‘FGD Details’ on the guide.
Obtain informed consent before recording the discussion
Record participant identifiers
Make sure you clearly indicate in your notes how you are
recording nonverbal behavior and your own comments
Record additional questions/probes by the facilitator
Indicate symbols for facilitator
– Place marks in margins that so that it is easily seen when you are scanning
the notes for completeness
– * could signify that a sentence or answer needed more clarity
8.
9.
10.
11.
Speak up if pace of FGD is too fast for recording
Coordinate with your team before closing the discussion
Complete the ‘FGD Participant Profile’ before participants leave
Stop and check the recording
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Recording Nonverbal Behavior
• Guidelines:
– First, does it add to the interpretation of the FGD?
– If yes,
• Write a short description of the behavior
• Provide some interpretation about what it means
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Example: Nonverbal Behavior
• “You know, we have hired assistants to work on
projects at [Organization redacted] and some of our
projects that I'm directly involved in-- some are
involved as staff, but yeah. So, um, because,
students like to do graduate assistant work and it,
ah (smiling and rubbing fingers together to indicate
money) get a little cash on the side.”
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Tracking Participant Responses
•
•
In your notebook, draw how participants are seated, and assign a number to
each person to track who says what.
If participants will move around, simply assign a number that you can
remember for each person.
Facilit
ator
Notetak
er
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Real life example
Question: What would you say are the barriers or
challenges for women to begin using contraceptives?
[2]: I know how to use methods (just pills), but there are challenges,
such as lack of awareness among both women and men. Husbands
prevent wives from using the pill. If I want to use it, I use it in a secret
way.
[4]: Using the pill will prevent women from having many children. Some
people produce ten children and some lose three. They remain with
seven children. If they take the pill, they may only have a few children,
and if they die, that will be bad luck. If we produce more than 12
children, if six die, we still remain with six.
[7]: Some forget to take the pill because of too much work. By the end
of the day, the mind is too tired and we cannot remember to take the
pill.
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Example continued
[1]: Fear of our husbands is another issue.
[3]: Small girls fear their parents and families. There is a lack of awareness and
incorrect information. There are also no CBD [community-based distribution] agents
in their area. The husband also opposes.
[Facilitator]: Is there anything else? Can you think of other reasons?
[5]: We need more information on how to be aware of the rest of the methods. For
condoms, we do not know how to use it. Even men cannot accept. We can only use
injections or pills.
Many nod their heads in agreement.
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Debriefing
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What is a debriefing session?
• Immediately following an activity, the facilitator and
notetaker should come together to discuss the
session and address areas of improvement.
1. Facilitator and notetaker review responses by
having the notetaker verbally review each response
that she or he has written for each question.
2. Facilitator can add any missed information.
3. Facilitator and notetaker discuss the responses for
any noteworthy thoughts.
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Debriefing at the End of the Day
• Make sure you understand the definition of terms or
phrases used in the local language:
– Get agreement from your team
– Keep a record of word in original language
• Debriefing is the start of analysis: you look at the data
and make sense of it
• When possible, return to key persons and ask
questions about things you do not understand
Transcription
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Expectations of the Transcriber
• Transcribe the FGD word for word (include every
word as spoken), include non-verbal observations
• Include facilitator’s questions and comments
• Include pauses, interruptions, laughter, silences, and
other unspoken dynamics in the transcript (use
notes)
• Include speaker identifiers where appropriate
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What happens during transcription?
• Once the data collection is finished, the research team will share
and discuss their notes.
• One note taker will merge the two sets of notes and translate
and type one transcript.
• In the process:
• Compare the transcript to the handwritten notes to match
speakers and add any missing information.
• Add any non-verbal observations that were noted by hand
so that the transcripts ultimately contain all of the information.
• Refrain from adding any identifying information (such as
names of people)
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Transcription Keys
Key
•[Text]
Indicates speech by the person who was not the primary speaker at the moment, i.e. “yeah”,
“Mmhmm”, or other short non-substantive affirmations, probes or interjections.
•[Text]
Description of body language or other environmental context.
•…
Indicates a pause. Length of pause indicated by number of dots: … vs. … …
•
Indicates that the sentence was cut short by an interjection by the other speaker.
•—
Indicates a quick transition in ideas, consistent with its typical grammatical use.
•?
Indicates that the sentence was spoken with a questioning tone, consistent with its typical
grammatical use.
•,
Indicates a natural transition pause while communicating a continuous thought, consistent with
its typical grammatical use.
•.
Indicates the natural end of one thought, followed by the beginning of a new one or speech by
the other speaker, consistent with its typical grammatical use.
• “____” Indicates that the speaker is imitating the speech of a third party who is not present, or is in fact
quoting a third party who is not present, consistent with its typical grammatical use.
•XXXX
Content redacted in order to de-identify the transcript.
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Important information about transcriptions:
• Transcriptions have to be written word for
word.
• Summaries, missing pauses, shortening
rambling statements, rephrasing, etc., cannot
be done.
• Everything that is said, along with actions and
gestures of importance, must be included in
your transcript.
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Introduce FGD Tools
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Wrap Up (End Day 1)
Day 2
82
Debrief from Day 1
83
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Guiding principles
• Speak slowly and clearly
• Repeat when needed
• Be courteous and attentive
– Do not yawn
– Take a break if they want
– Start with a friendly, welcoming atmosphere
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Guiding principles (2)
• Be neutral and accepting
– Do not use judgmental language
• Listen carefully to the answers
– Do not assume you know the answer
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Guiding principles (3)
• Establish and maintain boundaries
– Let the respondent know you are listening but also
focused on completing the interview
– Listen
– Maintain neutral role
• Pause if needed
• Stay focused on the respondent
– Avoid personal discussions about yourself
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Guiding principles (4)
• Treat the respondent with respect
• Do not act as a counselor
– We are not social workers
– If respondent is concerned, provide a referral to
services
– If you cannot handle a situation, discuss with
supervisor
Review Tools
88
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Practicing with examples…
• Facilitators
o Practice obtaining informed consent.
o Practice facilitating a short discussion or activity with
participants.
o Practice closing the discussion or group activity.
• Notetakers
o Practice taking notes and documenting observations.
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Practicing with examples…
• Participants
o Play different types of participants, including those with different
impairments, the talkative and quiet.
• Debrief
o Notetaker reviews group proceedings.
o Participants to point out any missed information and offer
suggestions to facilitators on ensuring inclusion and maximum
participation.
• Change roles
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Observe the process and answer the following
questions:
Does the interviewer introduce her/himself?
Does the interviewer ask for informed
consent?
Does the interviewer try to make the
interviewee comfortable? (i.e., good eye
contact, nodding of head, smiling,
encouraging behaviors)
Does the interviewer tell the interviewee
what to expect and how long the interview
might last?
91
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Practice Discussion
• What went well?
• What difficulties did you encounter
– Facilitator
– Notetakers
– Participants
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Wrap Up and Prepare for Pilot
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womensrefugeecommission.org
94
MISP Implementation
in Kathmandu and
Sindhupalchok, Nepal
Training: Focus Group Discussion (FGD)
September 10-12, 2015
Samira Sami, MPH
DrPH Candidate
Johns Hopkins University
Anna Myers, MPH
Research Manager
Women’s Refugee Commission
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1
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Agenda
•
Day 1: Training
– Introductions
– Staff roles and responsibilities
– Overview of the MISP
– Overview of the evaluation methodology
– Ethical issues and safety protocols
– Overview of focus group discussions (FGDs)
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Agenda (2)
•
Day 2: Training
– Introduction to FGD Tools
– Practice, practice, practice
•
Day 3: Pilot
– Conduct one male and female FGD
– Practice translation/transcription
– Debrief
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Introductions
•
•
•
•
What is your name?
Where are you from?
What are your favorite activities to do?
What is your research experience?
– Experience in qualitative research
– Experience in reproductive health research or
other work
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Staff Roles and Responsibilities
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Structure of Evaluation Team
Site 1: Kathmandu
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
Site 2: Sindhupalchok
1 Male Facilitator and 2 Male Notetakers
1 Female Facilitator and 2 Female Notetakers
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Roles/Responsibilities of Teams
Roles
Facilitator
Notetakers
Interpreter
Responsibilities
Timeliness
Respect
Be prepared
Team player
Ask questions!
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Timeline of Activities
Sunday
Monday
Tuesday Wednesday
Thursday
Friday
Saturday
6
7
8
9
10
Training
11
Training
12
Pilot
13
14
Data Collection
Day #1
15
Data
Collection
Day #2
16
Data Collection
Day #3
17
Data Collection
Day #4
18
Data Collection
Day #5
19
Debrief Day
20
21
Debrief with
stakeholders
22
23
24
25
26
Timeline
9
Timeline
10
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Communication Protocol
Security Issues
Administration
Hours and lateness
Housekeeping issues
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Planning FGD Schedule and
Participant Recruitment
List of health workers
How to recruit participants and informed consent
Selecting the right environment/setting
Scheduling dates/times for your FGDs
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QUESTIONS?
13
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Overview of the MISP
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Reproductive Health in Crisis
Settings
• WHY do we need to pay attention to RH in a crisis?
• 60% of preventable maternal deaths & 53% of child
deaths occur during crisis
• 4% of population pregnant at any time:
– 15% of pregnant women will need emergency obstetric care
– 9-15% of newborns will need live-saving emergency care
• Consequences of crisis can elevate mortality and sexual
violence
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Reproductive Health in Crisis
Settings (2)
• How does crisis worsen reproductive health?
–
–
–
–
–
–
Destruction of health facilities
Lack of trained staff
Health facilities overwhelmed
Breakdown of social structures, families
Lack of supplies
No access (displacement, security, cultural restrictions,
knowledge/attitudes towards HC, economics)
– Targeted and opportunistic sexual violence
– Sexual exploitation
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What is the Minimum Initial
Service Package (MISP) for
Reproductive Health?
• Minimum:
– Ensure basic, limited reproductive health services
• Initial:
– For use in emergencies, without site-specific needs
assessment
• Service:
– Health care for the population
• Package:
– Activities, supplies, coordination and planning
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Objective 1: Coordinating
implementation of MISP
priority RH services
Ensure the health sector/cluster
identifies an organization to lead
implementation of the MISP.
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Objective 2: Preventing and managing the
consequences of sexual violence
• Putting in place measures to protect
affected populations from sexual
violence
• Making clinical care available for
survivors of rape
• Ensuring the community is aware of
the available clinical services
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Objective 3: Reducing the spread of HIV
• Ensuring safe and rational blood
transfusions
• Enforcing respect for standard
precautions
• Guaranteeing the availability of
free condoms
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Objective 4: Preventing maternal and newborn death
and disability
• Ensuring availability and
accessibility of EmOC and newborn
care services at health facilities
and referral hospitals
• Establishing a referral system
• Providing clean delivery kits
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Objective 5: Planning for
Comprehensive RH Services
•Collecting existing background data
•Identifying suitable sites for
future RH service delivery
•Assessing staff capacity
•Ordering equipment and supplies
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Additional MISP Priorities
•Family Planning
•Sexually Transmitted Infections
•Prevention of Mother-to-Child
Transmission of HIV/AIDS
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QUESTIONS?
25
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Overview of Evaluation
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Evaluation Methodology
• Case study design
– Kathmandu
– Sindhupalchok
• Purposive sampling
• Population
– Program staff
– Health workers
– Community
• Methods:
– Key informant interviews
– Health facility assessments
– Focus group discussions
Method
Sampling plan
Data collection
strategy
Key informant
interviews
Program managers
and staff
• Semi-structured
interviews
Health facility
assessments
25 health facilities
• Structured
questionnaire
Focus group
discussions
32 focus groups
(male and female)
• Open ended
questions
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Evaluation of the Implementation of the MISP for RH
among Crisis-Affected Persons in Kathmandu and
Sindhupalchok, Nepal
•
Purpose of FGDs
– To qualitatively assess the extent that the MISP has been implemented
in Kathmandu and Sindhupalchok since the earthquake
•
FGD Objectives
1. To assess the extent that RH services are available and accessible
2. To explore how resources (human and material) relevant to the MISP
were allocated, mobilized, and delivered by agencies in the
humanitarian response
3. To explore awareness about and use of RH services by the crisisaffected population
4. To explore the factors that influence the implementation of the MISP
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Focus Group Discussions
•
•
Purpose: To understand the knowledge, attitudes, and access of RH
services among the crisis-affected population
Group composition: no more than 10 participants per group
Site 1 – Kathmandu
Site 2 – Sindhupalchowk
TOTAL
No. of FGDs No. of FGDs No. of FGDs
near health far from
near health
facilities
health
facilities
facilities
No. of FGDs No. of FGDs
far from
across all
health
sites
facilities
2
2
2
2
8
Boys aged 15-24 years 2
2
2
2
8
Women aged 25-49
years
Men aged 25-49 years
2
2
2
2
8
2
2
2
2
8
Age-Gender Group
Girls aged 15-24 years
32
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Evaluation Collaborators
Evaluation Team
Women’s Refugee Commission
Boston University School of Public Health
Johns Hopkins Bloomberg School of Public Health
RIDA research staff
Evaluation Partners
Department of Health (DOH) Nepal
United Nations Population Fund (UNFPA) Nepal
FPAN - SPRINT (Sexual and Reproductive Health Programme in
Crisis and Post-Crisis Situations)
Reproductive Health Sub-Cluster in Nepal
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Evaluation Outcomes
• Share findings with evaluation partners to inform the
development of program and policy recommendations
• Improve reproductive health services for people affected by
the earthquake in Nepal
• Disseminate final report for local and international learning
• Inform future emergencies by ensuring quality RH services
are provided to affected populations in similar contexts
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QUESTIONS?
33
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Lunch!
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Ethical Issues and Safety Protocols
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Principles of Ethical Research
• Respect integrity & minimize harm
• Informed consent
• Confidentiality
• Privacy
• Secure handling of data
• Sharing results with relevant stakeholders
• Understand the referral pathway for gender based violence
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Elements of Consent
• * If non-literate, read slowly in appropriate language and
ask for questions
• Introduction
•
•
•
•
•
•
Purpose of Study
Procedures
Risks & benefits
Questions or Concerns
Confidentiality
Voluntary Participation
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Practice: Informed Consent
• Read out loud
• Identify consent elements:
– Purpose of Study
– Procedures
– Risks and benefits
– Questions or concerns
– Confidentiality
– Voluntary Participation
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Eligible FGD Participants
• 18 and older → regular consent
• 15 to 17 years: must meet one of these
– Ever Married
– Pregnant
– Parent of a child
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Referral Pathway for Gender Based
Violence
•
See Handout
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Overview of Focus Group
Discussions
Quantitative vs. Qualitative Research
• Qualitative:
• Attempts to
explain
• Complex, changing
( ‘fluid’)
• Describes
meanings:
• Perceptions,
knowledge, beliefs,
behaviors
• Describe variation
• Behaviors
explained in
context of what is
happening around
them
• Quantitative:
• Attempts to
measure
• Often can
quantify an event
but NOT explain
why it occurred
• Standardized so
that larger
generalizations
can be made
42
Quantitative
43
Qualitative
What happens in a
house, how is a
“home” defined, what
influences what
people do in their
houses?
44
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What is qualitative research?
•
•
•
•
•
Qualitative research is flexible.
Non-leading questions and statements are used.
Information is probed as much as possible.
Participants are treated as the expert.
The participants lead the conversation while staying
on topic.
• How and why things happen are of most interest.
• The words people use are analyzed.
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No ‘right’ or ‘wrong’ –
we are trying to
understand perceptions
46
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What is a focus group discussion?
• A group interview that emphasizes
communication among group members in
order to generate information about a
chosen topic
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Why Do Focus Groups?
•
•
•
•
•
To collect information about knowledge, behaviors, what
people think, how they think and why they think that way
To discover variety within a homogenous population
To assess areas of agreement and disagreement between
groups
To develop a consensus view on a product
To empower participants, to hear their voices
* FGDs: NOT a way to interview a number of people at
once
Roles in a FGD
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• Facilitator - conducts the group interview
– Must be able to ask and clarify a question
– Hear the response
– Determine if further clarity is needed regarding the
responses
• Notetaker- records what is being said or expressed
–
–
–
–
–
–
Responsible for ensuring detailed documentation of the FG
Back-up to recording device
Captures quotes and who is speaking
Retain specific terms or phrases in local language
Record body language and nonverbal signals of participants
Remind facilitator of issues overlooked during the
discussion
• Both positions need to work together
The Facilitator
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50
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What are characteristics of good
facilitators?
•
•
•
•
•
•
Language and communication skills.
Familiarity with the content and structure of the activity.
Familiarity and comfort level with discussing reproductive health topics.
Ability to respect the dignity and confidentiality of participants.
Previous experience conducting focus groups or other qualitative activities.
Ability to multi-task and be flexible with adjusting questions as needed.
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Steps for Conducting a FGD
1. Prepare materials for FGD
2. Greet participants
3. Introduce yourself and the team
– Explain purpose of interview
– Describe link to local partners
4. Conduct informed consent
– Cannot promise other participants of the FGD will not
share
– Encourage FGD participants not to reveal identities
– Avoid using participant’s names during the FGD
– If participants refuse to participate, thank them for
their time and they can be excused from the group at
any time
5. Give a few brief group rules
– One speaker at a time
– No side conversations
– Everyone participating, no one dominating
How to Facilitate a FGD
(2)
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6. Move to first specific topic
– “Thank you. Let’s start with our first topic.”
– “One thing I’ve heard several people mention is _____. What else
can you say about that?” or “I’m surprised no one has mentioned
____. Does it matter or not?”
– Track connection between conversation and guide.
7. When closing, provide a summary of the
discussion
– Summarize key points of discussion with groups to
make sure important points have been captured.
– Ask if there’s anything else to add
– Don’t give out cookies/drinks until the end.
– Share the locations of existing services for
participants to access additional information and
services.
8.Prepare for debrief with research
team
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What is probing?
•
•
A way to encourage participants to say more and explain why or how to get
as much information as possible.
Types of probes are:
– Why or what questions: “What do you mean when you say…”
– Silent probe: Staying silent but supporting the participant to continue talking.
– Echo probe: Repeating the last point raised by the participant. “I see. You said that
people might talk to friends if they have a problem. Tell me more about that. What
happens then?” Be careful not to repeat something different than what was said,
as this would be leading.
– “Uh huh” probe : “oh,” “Uh-huh,” “I see”.
•
Other examples:
–
–
–
–
–
–
“Can you explain further?”
“Can you give me an example?”
“Can you say more?”
“I am not sure I understand x. Would you explain that to me?”
“How do you feel about…”
“Is there anything else?”
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What are good ways to probe?
•
•
•
•
•
•
•
“What do you mean when you say…”
“Can you explain further?”
“Can you give me an example?”
“Can you say more?”
“I am not sure I understand x. Would you explain that to me?”
“How do you feel about…”
“Is there anything else?”
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What is a leading question?
•
•
•
Leading questions are said in a way that suggests a particular answer
or implies that one answer is expected or more correct.
If leading questions are used, participants might be more likely to
agree with what we ask or think we are looking for a particular answer.
Participants are less likely to say what they really think.
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What is a leading question?
Leading questions:
• “What fears do you have when your baby’s diarrhea does
not stop?”
• “Why didn’t you take your baby to the health center for
treatment?”
• “How good was the treatment at the health center?”
Non-leading questions:
• “What do you think about when your baby’s diarrhea does
not stop?”
• “What do you do when her/his diarrhea does not stop?”
• “How do you feel about the treatment your baby got at the
health center?”
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Troubleshooting
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58
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How should a facilitator facilitate?
•
•
•
•
•
•
•
Listen to participants and concentrate on what they are saying.
Ask questions one at a time.
Show interest and understanding.
Encourage participants to feel comfortable sharing as much information
as possible.
Remind participants to share information about the general situation
and not their personal situation.
Listen for causes and characteristics of an issue.
Be silent when silence is needed.
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What are things the facilitator should avoid?
•
•
•
•
•
•
•
•
•
•
Nodding your head, smiling, frowning or using other body movement that
can show a biased or judgmental attitude.
Giving answers to the questions and/or agreeing verbally with the
answers.
Being impatient.
Judging the answers (e.g., saying, “It is good”).
Cutting off the participants’ answers in the middle of their sentences.
Letting two or more participants talk at the same time.
Sharing your personal opinions.
Arguing with participants.
Losing control of the discussion to participants that dominate the
conversation.
Skipping any participant during the discussions.
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What are examples of participants you may
need to manage?
Challenge
Suggested Response
Talkative
Thank them for their contribution
Invite others to comment
Encourage them to make one point at a time
Asking lots of questions
Write question on flip chart and return to them
Prioritize which questions to focus on
Tired
Take a break
Anger
Acknowledge emotion or sensitivity
Steer towards sensitive issue rather than person
Shy
Encourage to contribute by calling pseudo name
Ask if agrees/disagrees with what has been shared
Personalities
Use pleasant and patient tone
Add humor, where appropriate
Full agreement
Jot down your thoughts
first, now let’s discuss
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How can different participants be managed?
•
Participants that are “the expert,” too talkative, rambling or politically
inclined:
o Use verbal and non-verbal communication, such as body motion and
eye contact.
o Repeat the topic question so that the participant understands the
topic.
• Participants that are scared, shy or confused:
o Give more attention and encouragement through using eye contact
and by being patient.
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The Notetaker
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63
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What are characteristics of good
notetakers?
•
•
•
•
•
•
•
Excellent listening skills with the ability to listen while writing notes in an
format without slowing the tempo of the discussion unnecessarily.
Able to write verbal and non-verbal responses
Ability to listen without making comments
Ability to respect the dignity and confidentiality of respondents.
Ability to multi-task and recognize when the facilitator has altered the
sequence of the questions, which requires a strong familiarity with the
study tool.
Date must be recorded in a format that is readable, understandable, and
complete
Ability to concentrate and write notes for a period of up to 2 hours in length.
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Expectations of the Notetakers
•
•
•
•
Assign speaker identifiers and note who says what
Retain specific terms or phrases in local language
Record body language and nonverbal signals of participants
Remind facilitator of issues overlooked during the discussion
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How to Record a FGD
1.
2.
3.
4.
5.
6.
7.
Prepare the audio recorder and environment for the discussions
Document the ‘FGD Details’ on the guide.
Obtain informed consent before recording the discussion
Record participant identifiers
Make sure you clearly indicate in your notes how you are
recording nonverbal behavior and your own comments
Record additional questions/probes by the facilitator
Indicate symbols for facilitator
– Place marks in margins that so that it is easily seen when you are scanning
the notes for completeness
– * could signify that a sentence or answer needed more clarity
8.
9.
10.
11.
Speak up if pace of FGD is too fast for recording
Coordinate with your team before closing the discussion
Complete the ‘FGD Participant Profile’ before participants leave
Stop and check the recording
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Recording Nonverbal Behavior
• Guidelines:
– First, does it add to the interpretation of the FGD?
– If yes,
• Write a short description of the behavior
• Provide some interpretation about what it means
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Example: Nonverbal Behavior
• “You know, we have hired assistants to work on
projects at [Organization redacted] and some of our
projects that I'm directly involved in-- some are
involved as staff, but yeah. So, um, because,
students like to do graduate assistant work and it,
ah (smiling and rubbing fingers together to indicate
money) get a little cash on the side.”
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Tracking Participant Responses
•
•
In your notebook, draw how participants are seated, and assign a number to
each person to track who says what.
If participants will move around, simply assign a number that you can
remember for each person.
Facilit
ator
Notetak
er
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Real life example
Question: What would you say are the barriers or
challenges for women to begin using contraceptives?
[2]: I know how to use methods (just pills), but there are challenges,
such as lack of awareness among both women and men. Husbands
prevent wives from using the pill. If I want to use it, I use it in a secret
way.
[4]: Using the pill will prevent women from having many children. Some
people produce ten children and some lose three. They remain with
seven children. If they take the pill, they may only have a few children,
and if they die, that will be bad luck. If we produce more than 12
children, if six die, we still remain with six.
[7]: Some forget to take the pill because of too much work. By the end
of the day, the mind is too tired and we cannot remember to take the
pill.
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Example continued
[1]: Fear of our husbands is another issue.
[3]: Small girls fear their parents and families. There is a lack of awareness and
incorrect information. There are also no CBD [community-based distribution] agents
in their area. The husband also opposes.
[Facilitator]: Is there anything else? Can you think of other reasons?
[5]: We need more information on how to be aware of the rest of the methods. For
condoms, we do not know how to use it. Even men cannot accept. We can only use
injections or pills.
Many nod their heads in agreement.
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Debriefing
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72
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What is a debriefing session?
• Immediately following an activity, the facilitator and
notetaker should come together to discuss the
session and address areas of improvement.
1. Facilitator and notetaker review responses by
having the notetaker verbally review each response
that she or he has written for each question.
2. Facilitator can add any missed information.
3. Facilitator and notetaker discuss the responses for
any noteworthy thoughts.
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Debriefing at the End of the Day
• Make sure you understand the definition of terms or
phrases used in the local language:
– Get agreement from your team
– Keep a record of word in original language
• Debriefing is the start of analysis: you look at the data
and make sense of it
• When possible, return to key persons and ask
questions about things you do not understand
Transcription
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75
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Expectations of the Transcriber
• Transcribe the FGD word for word (include every
word as spoken), include non-verbal observations
• Include facilitator’s questions and comments
• Include pauses, interruptions, laughter, silences, and
other unspoken dynamics in the transcript (use
notes)
• Include speaker identifiers where appropriate
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What happens during transcription?
• Once the data collection is finished, the research team will share
and discuss their notes.
• One note taker will merge the two sets of notes and translate
and type one transcript.
• In the process:
• Compare the transcript to the handwritten notes to match
speakers and add any missing information.
• Add any non-verbal observations that were noted by hand
so that the transcripts ultimately contain all of the information.
• Refrain from adding any identifying information (such as
names of people)
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Transcription Keys
Key
•[Text]
Indicates speech by the person who was not the primary speaker at the moment, i.e. “yeah”,
“Mmhmm”, or other short non-substantive affirmations, probes or interjections.
•[Text]
Description of body language or other environmental context.
•…
Indicates a pause. Length of pause indicated by number of dots: … vs. … …
•
Indicates that the sentence was cut short by an interjection by the other speaker.
•—
Indicates a quick transition in ideas, consistent with its typical grammatical use.
•?
Indicates that the sentence was spoken with a questioning tone, consistent with its typical
grammatical use.
•,
Indicates a natural transition pause while communicating a continuous thought, consistent with
its typical grammatical use.
•.
Indicates the natural end of one thought, followed by the beginning of a new one or speech by
the other speaker, consistent with its typical grammatical use.
• “____” Indicates that the speaker is imitating the speech of a third party who is not present, or is in fact
quoting a third party who is not present, consistent with its typical grammatical use.
•XXXX
Content redacted in order to de-identify the transcript.
Research. Rethink. Resolve.
Important information about transcriptions:
• Transcriptions have to be written word for
word.
• Summaries, missing pauses, shortening
rambling statements, rephrasing, etc., cannot
be done.
• Everything that is said, along with actions and
gestures of importance, must be included in
your transcript.
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Introduce FGD Tools
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Wrap Up (End Day 1)
Day 2
82
Debrief from Day 1
83
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Guiding principles
• Speak slowly and clearly
• Repeat when needed
• Be courteous and attentive
– Do not yawn
– Take a break if they want
– Start with a friendly, welcoming atmosphere
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Guiding principles (2)
• Be neutral and accepting
– Do not use judgmental language
• Listen carefully to the answers
– Do not assume you know the answer
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Guiding principles (3)
• Establish and maintain boundaries
– Let the respondent know you are listening but also
focused on completing the interview
– Listen
– Maintain neutral role
• Pause if needed
• Stay focused on the respondent
– Avoid personal discussions about yourself
Research. Rethink. Resolve.
Guiding principles (4)
• Treat the respondent with respect
• Do not act as a counselor
– We are not social workers
– If respondent is concerned, provide a referral to
services
– If you cannot handle a situation, discuss with
supervisor
Review Tools
88
Research. Rethink. Resolve.
Practicing with examples…
• Facilitators
o Practice obtaining informed consent.
o Practice facilitating a short discussion or activity with
participants.
o Practice closing the discussion or group activity.
• Notetakers
o Practice taking notes and documenting observations.
Research. Rethink. Resolve.
Research. Rethink. Resolve.
Practicing with examples…
• Participants
o Play different types of participants, including those with different
impairments, the talkative and quiet.
• Debrief
o Notetaker reviews group proceedings.
o Participants to point out any missed information and offer
suggestions to facilitators on ensuring inclusion and maximum
participation.
• Change roles
Research. Rethink. Resolve.
Observe the process and answer the following
questions:
Does the interviewer introduce her/himself?
Does the interviewer ask for informed
consent?
Does the interviewer try to make the
interviewee comfortable? (i.e., good eye
contact, nodding of head, smiling,
encouraging behaviors)
Does the interviewer tell the interviewee
what to expect and how long the interview
might last?
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Research. Rethink. Resolve.
Practice Discussion
• What went well?
• What difficulties did you encounter
– Facilitator
– Notetakers
– Participants
Research. Rethink. Resolve.
Wrap Up and Prepare for Pilot
Research. Rethink. Resolve.
womensrefugeecommission.org
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