Nurse Researcher
International research
Conducting international nursing research: challenges and opportunities Cite this article as: Opollo J, Opollo D, Gray J, Spies L (2014) Conducting international nursing research: challenges and opportunities. Nurse Researcher. 22, 2, 29-33. Date of submission: February 9 2013. Date of acceptance: January 2 2014 Correspondence to [email protected]
Abstract
Jackline Gloria Opollo PhD, RN, MSN, MPH is director of professional practice and nursing research at Parkland Health & Hospital System, Dallas, Texas, US
Aim To describe practical experiences before, during and after gaining entry into research fields in Kenya and Uganda.
and creative when handling methodological, ethical and logistical challenges encountered in settings poor in resources.
Diana Alaka Opollo PhD, LMSW, BA is a senior research fellow at the Management University of Africa, Nairobi, Kenya
Background Planning, conducting and implementing international research can be an arduous task. Novice researchers need practical guides to accessing international fields and mitigating challenges met in the field.
Conclusion International research provides opportunities for increasing dedication, building cross-cultural competence and advancing health professional practice globally.
Jennifer Gray PhD, RN is associate dean/chair and professor, College of Nursing, at the University of Texas, Arlington, Texas, US
Data sources The researchers conducted three different studies in two developing nations.
Lori Spies PhD, RN, MS, NP-C is assistant professor, Family Nurse Practitioner Program Missions co-ordinator, at Baylor University, Waco, Texas, US Peer review This article has been subject to double-blind peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nr-author-guidelines
Review methods This paper reviews challenges encountered when conducting international research. Solutions used to overcome these challenges are discussed. Discussion Establishing and maintaining effective partnerships is critical to the success of international research efforts. Researchers must be tactful, flexible
Introduction International cross-cultural research is critical in advancing professional healthcare practice globally (Suhonen et al 2009). The phrase ‘10/90 gap’ refers to the notion that less than 10% of global resources for health care and healthcare research are directed towards the problems of developing countries, which bear more than 90% of the burden of global disease (Global Forum for Health Research 2004). Global challenges, including the spread of communicable diseases and international migration, are key issues
© RCN PUBLISHING / NURSE RESEARCHER
Implications for research/practice This paper contributes to nursing scholarship by highlighting the practical challenges of conducting international research. Illustrations aimed at lending insight and encouraging others to expand their dedication to conducting international research are offered. Keywords International research, global, nursing research, social sciences research, cross‑cultural research, developing countries, Kenya, Uganda
affecting health and health care globally (Pinto and Upshur 2009). Students interested in global healthcare careers should seek opportunities to conduct research in developing countries (Suhonen et al 2009, Provenzano et al 2010). Conducting international research often presents conceptual, philosophical, methodological, operational and financial challenges (Suhonen et al 2009). Practical guides are needed on how to mitigate such challenges and how to gain and maintain access to international research fields (Johl and Renganathan 2010). November 2014 | Volume 22 | Number 2 29
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Art & science | acute care Nurse Researcher Background of research studies A brief description of three studies is presented to provide the context for issues discussed in this paper. The mixed methods study (Opollo 2012) – hereinafter referred to as the ‘Stigma study’ – explored the extent of stigma against HIV-positive healthcare workers (HCWs) in Kenya. The second study (WRQoL study) aimed to measure perceived work-related quality of life (WRQoL) among Ugandan HCWs (Opollo et al 2014). The third study (Opollo 2011) – hereinafter referred to as ‘secondary analysis’ – was conducted in the US while accessing an electronic database in Kenya. This study provides insight into how one can conduct research with broad international implications without travelling to another country. The purpose of this paper is to describe the authors’ experiences before, during and after gaining entry to research fields in Kenya and Uganda. Challenges met and solutions used to mitigate challenges encountered are discussed for consideration by others interested in conducting international research.
Gaining entry Once a research plan has been formulated, the most challenging task in field research is gaining entry (Shenton and Hayter 2004, Johl and Renganathan 2010). This involves securing access to organisations and recruiting participants for the study (Shenton and Hayter 2004). Researchers must be tactful when gaining access to participants. Possible tactics include: strengthening links with organisations; maintaining honest and open communication; citing support from authorities; phasing entry into research fields; reciprocating benefits of a study; and demonstrating professional suitability (Shenton and Hayter 2004, Johl and Renganathan 2010). In the case of the studies mentioned in this paper, the researchers’ formal and informal networks with scholars in Kenya and Uganda over the past five years proved to be invaluable in gaining access to research informants. Open and honest communication with gatekeepers and potential participants was achieved by providing clear outlines of the purpose of the study and reasons for the choices of fieldwork sites, and assuring confidentiality and anonymity. Professional suitability was demonstrated by highlighting the researchers’ personal, academic and professional credentials, and sharing past papers, poster presentations and research proposals with key individuals. The researchers’ commitment, awareness of wider professional trends in Uganda, and endorsement by the Ugandan Nurses and 30 November 2014 | Volume 22 | Number 2
Midwives Union (UNMU) and Makerere University (MU) established legitimacy for the WRQoL study; grant funding from Sigma Theta Tau International (STTI) established credibility for the stigma study. The researchers demonstrated good intentions by striking bargains that would ensure benefit for the researchers, institutions and individuals involved. Subjects in the stigma study received modest compensation for their participation. Emphasis was placed on the value of personal and institutional contributions. To strengthen the spirit of reciprocity, the researchers agreed to disseminate study findings through publications, oral presentations and formal reports to stakeholders.
Practical experiences, challenges and solutions Entry into research fields consists of four stages: ‘pre-entry’, ‘during fieldwork’, ‘after fieldwork’ and ‘getting back’ (Figure 1). These involve a variety of activities that are not sequential but iterative (Shenton and Hayter 2004, Johl and Renganathan 2010). Pre-entry Historically justified mistrust between local partners and foreign researchers can interfere with research (Stenson et al 2010). During pre-entry, the researcher focuses on processes, activities and tactics that help to smooth entry into the field before data are collected (Johl and Renganathan 2010). Issues are addressed relating to building partnerships, researcher match and obtaining ethics approval and funding. Researcher match means that researchers must assess their qualifications to conduct the study in a foreign country, as well as their understanding of the traditions, values, family systems, socioeconomic issues, attitudes and social policies of the country. Having a gatekeeper who vouches for the study is integral in building web relationships and creating new relationships with others (Johl and Renganathan 2010). For the stigma study, the researchers’ relationships with HIV/AIDS networks in Kenya provided an opportunity for networking with MildMay International, a non-governmental organisation (NGO) committed to building capacity for HCWs in HIV/ AIDS environments. The NGO helped the researchers to access multiple informants and provided transport to research sites. For the WRQoL study, the researchers’ long-standing relationships with UNMU and MU aided in creating new relationships and strengthened existing relationships with affiliated partners in rural and urban Uganda. Speaking the same language and being of the same ethnicity as research participants can influence © RCN PUBLISHING / NURSE RESEARCHER
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International research
■■Access individual subjects
■■Data collection ■■Address cultural and
■■Data storage ■■Data analysis ■■Follow-up communication ■■Disseminate findings
Ge ba tting ck
-e n
tr y
ethical issues
Pr e
framework ■■Establish relationships ■■Build trust and credibility ■■Address researcher match concerns ■■Obtain ethics approval
g rin ork Du d w l fie
© RCN PUBLISHING / NURSE RESEARCHER
■■Adapt an ethical
r te rk Af wo ld
During fieldwork Here researchers must contend with ethics, logistics, cultural concerns, data collection, informed consent and access to participants. For the stigma sudy, the researcher (JO) attended a support group meeting for HIV-positive HCWs in Nairobi, Kenya before beginning research in Kisumu. Through active listening and observation, she gained insight into interactions and processes that occur in support groups. This effort promoted acceptance by participants. Furthermore, it informed the researcher’s approach to qualitative interview
Figure 1 Gaining entry into research fields
fie
the degree of cultural competence of a researcher (Rubin and Babbie 2008). Two of the researchers are natives of Kenya while the other two are natives of the US; all four live in the US. To avoid being viewed as outsiders and to address issues of power differentials that are common for studies funded in wealthy nations and carried out in foreign locations (Murphy et al 2006), the researchers talked with residents about local news. The secondary analysis was unique since the research was being conducted remotely without face-to-face interaction. The researchers established rapport with Ugandan and Kenyan partners through frequent email, telephone and digital audiovisual communication such as Skype. Before embarking on international research experiences, students should be trained in research methods and ethics (Pinto and Upshur 2009, Provenzano et al 2010). An ethical framework can help to guide researchers dealing with ethical dilemmas in the field (Pinto and Upshur 2009). Ideally, researchers should collaborate with a faculty member at the institution where they will conduct the research (Murphy et al 2006). For all the studies mentioned in this paper, the researchers encouraged country partners to provide feedback on the relevance of the research instruments before the study began. Additionally, Ugandan and Kenyan faculty members were instrumental in mitigating practical and political issues surrounding ethics approval, which was obtained from the research sites in Kenya, Uganda and the US. The STTI grant and an endowed professorship fund helped to cover local expenses for the stigma study and the WRQOL study. Minimal expenses were incurred for the secondary analysis study. Consulting with family, friends and gatekeepers in host countries provided insight into the average costs of miscellaneous expenses. To avoid being overcharged, the researchers frequently travelled in the company of locals who negotiated to obtain the same prices as those charged to residents.
■■Manage logistical concerns
■■ Collect additional information
■■ Clarify issues ■■ Lay groundwork for future research and collaborations
sessions in the field. The researcher (JO) also built rapport and trust with participants by dressing appropriately, speaking clearly, minimising their use of jewellery and accessories, speaking in local dialects, travelling on local public transport and encouraging participants to use the researchers’ first names. Accessing individuals for the WRQoL study was easier because potential participants were attending planned nursing development workshops. For the stigma study, gatekeepers of HIV/AIDS support groups in Kenya were instrumental in obtaining access to participants. Most participants opted to meet the researcher (JO) at a central guesthouse but whenever necessary, the researcher travelled to meet participants at their preferred sites. Since travel to remote sites can be expensive and time-consuming, creating an interview timetable that provides adequate time for travel to and from research sites is important. Researchers must remember that transaction practices vary globally (Murphy et al 2006). For example, obtaining receipts for transport at the end of each journey may not always be possible. However, funding agencies require documentation accounting for use of research funds. One possibility, therefore, is for researchers to travel with pre-printed, generic receipt books and have vendors sign and justify payment for services rendered. When access to essential informants is denied, researchers can use alternative routes (Shenton and Hayter 2003). In the stigma study, a key person at one hospital demanded copies of November 2014 | Volume 22 | Number 2 31
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Art & science | acute care Nurse Researcher the research protocol for further review by the hospital’s research board. The researcher (JO) was asked to pay additional fees for this. Due to time constraints and the fact that the researcher did not encounter this challenge at other hospitals, the researcher decided to use an alternative route to recruit participants: snowballing and purposive sampling with the assistance of the primary gatekeeper. Once a researcher is in the field, some survey items for studies may need to be refined. For example, cadres identified in the stigma study included the terms ‘staff nurse’, ‘professional nursing sister’ and ‘community health worker’. Subjects who identified themselves as ‘community health registered nurses’ found these categories confusing. In addition, the survey item on annual income proved cumbersome for participants in the stigma study as the item did not specify gross or net. Subjects had to use their calculators to estimate their annual salaries. ‘Monthly gross salary’ was identified as more acceptable. The issue of defining oneself as an ethnic minority is common in surveys designed in the West. Like Kenya, Uganda is a country with diverse cultures. Several participants in the WRQoL study found the following question on the demographic survey irrelevant: ‘Do you consider yourself a member of an ethnic minority?’ Thus, responses to this question were discarded during the final analysis. To avoid such challenges, researchers should pilot test measurement instruments in a small sample of potential research participants. In the WRQoL study, 171 participants completed self-administered questionnaires but only146 surveys were used in the final analysis because of missing values. Missing data was not an issue in the stigma study because the instrument was a one-on-one, semi-structured, face-to-face interview in which the researcher recorded participants’ responses to the questionnaire. The secondary analysis had large missing values and these were adjusted for using advanced statistical methods. It is widely assumed that Western ethics training is applicable to global health experiences (Pinto and Upshur 2009). However, threats to rigour may occur when collecting data because of variations in culture and context. This may hinder executing a research protocol exactly as planned. In one instance in Kenya, the researcher (JO) suggested one participant should attend to a patient’s needs first, but the participant adamantly completed the study. Subjects also frequently skimmed through informed consent documents. 32 November 2014 | Volume 22 | Number 2
When this happens, researchers should reiterate points regarding informed consent by asking a uniform set of simple questions about study risks and benefits (Stenson et al 2010). In rural Uganda, it was apparent that the workshops’ participants required more time to read the informed consent documents. Due to time constraints, the research team provided consent forms at the end of the workshops and encouraged participants to take the documents home to review. Participants who attended the workshops on the second day signed consent forms and then completed the survey instruments. In Uganda, some participants at clinics requested that the researcher leave survey forms with them and return to pick them up at the end of the day. Researchers need to be flexible and receptive to suggestions from participants. Although the researchers lost some control, they felt that it was ethical to have participants attend to patients’ needs first, as well as to have adequate time to read and understand the consent document. To minimise groupthink, the researchers instructed participants not to share answers or discuss their responses. Compensation for participants in research remains a topic for debate (Stenson et al 2010). Murphy et al (2006) suggested that offering US$10 for two hours’ work in a country where the daily wage is US$5 can be coercive. Stenson et al (2010) suggested that alternative forms of compensation, such as food, supplies and other tangible items, may be considered more valuable than cash. They recommended that participants be compensated with items they are unlikely to purchase and which have secondary benefits, such as education, nutrition and empowerment. Once the researcher is on the ground in a foreign country it may be necessary to make some changes to the research plan based on the country context. Thus, when conducting international research, researchers must be flexible and build in some extra time within their research plan in anticipation of the potential for ethics approval modification once in the field. For example, for the stigma study, the researcher (JO) had obtained approval for compensation for each participant of mobile phone airtime valued at US$12. On arrival in Kenya, it became apparent that there are several mobile phone companies so any prior effort to purchase airtime would have been cumbersome and potentially wasteful since the researcher had no way of anticipating the participants’ network providers. Following consultation with partners in © RCN PUBLISHING / NURSE RESEARCHER
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International research Kenya and after ethics approval modification, it was resolved to offer each participant the equivalent of US$12 (KSh1,000). Researchers must also anticipate challenges from common hidden costs, including cashpoints, the exchange of currency and bank fees (Murphy et al 2006). To avoid carrying large amounts of cash in Kenya, the researcher used local mobile banking M-PESA kiosks – a relatively cheap, secure and convenient electronic way to manage cash. Post-entry After collecting data, researchers must contend with the issues of leaving the field, storing and analysing data, and maintaining contact with key individuals. For the stigma study, the researcher (JO) hired a local transcriptionist, trained in protecting research participants. This expedited data analysis, was cost-effective, saved time and ensured accuracy, since the transcriptionist was familiar with local language intonations and expressions. Furthermore, it provided a resident with a job, in an area where such opportunities are often scarce. Data handling and storage in the field can be cumbersome. Materials must be stored in safe places and electronic files must be password-protected. Analysis can be hindered by restrictions placed on measurement instruments by their authors. Instruments for the stigma study and the WRQoL study are available for free and scoring information for the stigma study was easily accessible. However, the researchers could not obtain scoring information for the WRQoL study. Instead, the tool’s developers offered to analyse the data in return for anonymised copies of the data for their benchmarking database. Finally, leaving the field can be emotional for researchers and participants. Participants may solicit from researchers help related to personal matters. In Kenya and Uganda, some participants wanted to know if the researchers could help them to emigrate to the US or assist them financially. It is important for researchers to acknowledge the challenges
presented to them by individuals in the field, while keeping their role as researcher separate. Stenson et al (2010) highlighted the importance of appreciating the contributions of research staff, to maintain the integrity of a research programme. Murphy et al (2006) urged international researchers to identify creative ways to compensate collaborators, including culturally appropriate gifts. If contact information is available, ‘thank you’ cards and follow-up emails are important in maintaining rapport. Re-entry Getting back into the field may not always be necessary. However, researchers should maintain rapport with gatekeepers throughout all the stages of the study, which could assist with re-entry to collect additional information or clarify issues if necessary. For instance, in the stigma study, the researcher (JO) left some documents in Kisumu. The researcher had established and maintained rapport with the gatekeepers, which proved invaluable as they returned the documents to the researcher safely. Providing contact information to participants and voluntary communication between participants and researchers are encouraged. These are integral in sustaining relationships and laying the groundwork for future research targeting vulnerable, hard-to-reach populations (Johl and Renganathan 2010, Stenson et al 2010).
Conclusion Despite the many challenges, conducting international research has significant implications for research, education, policy and practice. International research provides opportunities for building cultural competence, enhancing effective international partnerships and collaborations, and generating knowledge that can inform policy changes. It is imperative that educators use innovative strategies to integrate global healthcare research concepts into the curricula of healthcare professions.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Global Forum for Health Research (2004) The 10/90 Report on Health Research 2003-2004. GFHR, Geneva, Switzerland.
Opollo DA (2011) Modernization and Contraception in Kenya from 1998 to 2008-2009. Doctoral dissertation.
Pinto AD, Upshur RE (2009) Global health ethics for students. Developing World Bioethics. 9, 1, 1-10.
Johl SK, Renganathan S (2010) Strategies for gaining access in doing fieldwork: reflection of two researchers. The Electronic Journal of Business Research Methods. 8, 1, 42-50.
Opollo JG (2012) Extent Of HIV Stigma Among HIV Positive Healthcare Workers: A Mixed Methods Approach. Doctoral dissertation.
Provenzano AM, Graber LK, Elansary M et al (2010) Short term global health research projects by US medical students: ethical challenges for partnerships. American Journal of Tropical Medicine and Hygiene. 83, 2, 211-214.
Murphy AD, Perilla JL, Jones E (2006) Conducting research in other countries. In Norris FH, Galea S, Friedman MJ, et al (Eds) Methods For Disaster Mental Health Research. The Guilford Press, New York NY.
Opollo JG, Gray J, Spies LA (2014) Work Related Quality of Life of Ugandan Nurses: A Descriptive Study. International Nursing Review. 61, 1, 116-123.
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Shenton AK, Hayter S (2004) Strategies for gaining access to organisations and informants in qualitative studies. Education for Information. 22, 223-231. Stenson AL, Kapungu CT, Geller SE et al (2010) Navigating the challenges of global reproductive health research. Journal of Women’s Health. 19, 11, 2101-2107.
Rubin A, Babbie ER (2008) Research Methods For Social Work. Sixth edition. Brooks/Cole, Cengage Learning, Belmont CA.
Suhonen R, Saarikoski M, Leino-Kilpi H (2009) Cross-cultural nursing research. International Journal of Nursing Studies. 46, 4, 593-602.
November 2014 | Volume 22 | Number 2 33
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International research
Conducting international nursing research: challenges and opportunities Cite this article as: Opollo J, Opollo D, Gray J, Spies L (2014) Conducting international nursing research: challenges and opportunities. Nurse Researcher. 22, 2, 29-33. Date of submission: February 9 2013. Date of acceptance: January 2 2014 Correspondence to [email protected]
Abstract
Jackline Gloria Opollo PhD, RN, MSN, MPH is director of professional practice and nursing research at Parkland Health & Hospital System, Dallas, Texas, US
Aim To describe practical experiences before, during and after gaining entry into research fields in Kenya and Uganda.
and creative when handling methodological, ethical and logistical challenges encountered in settings poor in resources.
Diana Alaka Opollo PhD, LMSW, BA is a senior research fellow at the Management University of Africa, Nairobi, Kenya
Background Planning, conducting and implementing international research can be an arduous task. Novice researchers need practical guides to accessing international fields and mitigating challenges met in the field.
Conclusion International research provides opportunities for increasing dedication, building cross-cultural competence and advancing health professional practice globally.
Jennifer Gray PhD, RN is associate dean/chair and professor, College of Nursing, at the University of Texas, Arlington, Texas, US
Data sources The researchers conducted three different studies in two developing nations.
Lori Spies PhD, RN, MS, NP-C is assistant professor, Family Nurse Practitioner Program Missions co-ordinator, at Baylor University, Waco, Texas, US Peer review This article has been subject to double-blind peer review and checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nr-author-guidelines
Review methods This paper reviews challenges encountered when conducting international research. Solutions used to overcome these challenges are discussed. Discussion Establishing and maintaining effective partnerships is critical to the success of international research efforts. Researchers must be tactful, flexible
Introduction International cross-cultural research is critical in advancing professional healthcare practice globally (Suhonen et al 2009). The phrase ‘10/90 gap’ refers to the notion that less than 10% of global resources for health care and healthcare research are directed towards the problems of developing countries, which bear more than 90% of the burden of global disease (Global Forum for Health Research 2004). Global challenges, including the spread of communicable diseases and international migration, are key issues
© RCN PUBLISHING / NURSE RESEARCHER
Implications for research/practice This paper contributes to nursing scholarship by highlighting the practical challenges of conducting international research. Illustrations aimed at lending insight and encouraging others to expand their dedication to conducting international research are offered. Keywords International research, global, nursing research, social sciences research, cross‑cultural research, developing countries, Kenya, Uganda
affecting health and health care globally (Pinto and Upshur 2009). Students interested in global healthcare careers should seek opportunities to conduct research in developing countries (Suhonen et al 2009, Provenzano et al 2010). Conducting international research often presents conceptual, philosophical, methodological, operational and financial challenges (Suhonen et al 2009). Practical guides are needed on how to mitigate such challenges and how to gain and maintain access to international research fields (Johl and Renganathan 2010). November 2014 | Volume 22 | Number 2 29
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Art & science | acute care Nurse Researcher Background of research studies A brief description of three studies is presented to provide the context for issues discussed in this paper. The mixed methods study (Opollo 2012) – hereinafter referred to as the ‘Stigma study’ – explored the extent of stigma against HIV-positive healthcare workers (HCWs) in Kenya. The second study (WRQoL study) aimed to measure perceived work-related quality of life (WRQoL) among Ugandan HCWs (Opollo et al 2014). The third study (Opollo 2011) – hereinafter referred to as ‘secondary analysis’ – was conducted in the US while accessing an electronic database in Kenya. This study provides insight into how one can conduct research with broad international implications without travelling to another country. The purpose of this paper is to describe the authors’ experiences before, during and after gaining entry to research fields in Kenya and Uganda. Challenges met and solutions used to mitigate challenges encountered are discussed for consideration by others interested in conducting international research.
Gaining entry Once a research plan has been formulated, the most challenging task in field research is gaining entry (Shenton and Hayter 2004, Johl and Renganathan 2010). This involves securing access to organisations and recruiting participants for the study (Shenton and Hayter 2004). Researchers must be tactful when gaining access to participants. Possible tactics include: strengthening links with organisations; maintaining honest and open communication; citing support from authorities; phasing entry into research fields; reciprocating benefits of a study; and demonstrating professional suitability (Shenton and Hayter 2004, Johl and Renganathan 2010). In the case of the studies mentioned in this paper, the researchers’ formal and informal networks with scholars in Kenya and Uganda over the past five years proved to be invaluable in gaining access to research informants. Open and honest communication with gatekeepers and potential participants was achieved by providing clear outlines of the purpose of the study and reasons for the choices of fieldwork sites, and assuring confidentiality and anonymity. Professional suitability was demonstrated by highlighting the researchers’ personal, academic and professional credentials, and sharing past papers, poster presentations and research proposals with key individuals. The researchers’ commitment, awareness of wider professional trends in Uganda, and endorsement by the Ugandan Nurses and 30 November 2014 | Volume 22 | Number 2
Midwives Union (UNMU) and Makerere University (MU) established legitimacy for the WRQoL study; grant funding from Sigma Theta Tau International (STTI) established credibility for the stigma study. The researchers demonstrated good intentions by striking bargains that would ensure benefit for the researchers, institutions and individuals involved. Subjects in the stigma study received modest compensation for their participation. Emphasis was placed on the value of personal and institutional contributions. To strengthen the spirit of reciprocity, the researchers agreed to disseminate study findings through publications, oral presentations and formal reports to stakeholders.
Practical experiences, challenges and solutions Entry into research fields consists of four stages: ‘pre-entry’, ‘during fieldwork’, ‘after fieldwork’ and ‘getting back’ (Figure 1). These involve a variety of activities that are not sequential but iterative (Shenton and Hayter 2004, Johl and Renganathan 2010). Pre-entry Historically justified mistrust between local partners and foreign researchers can interfere with research (Stenson et al 2010). During pre-entry, the researcher focuses on processes, activities and tactics that help to smooth entry into the field before data are collected (Johl and Renganathan 2010). Issues are addressed relating to building partnerships, researcher match and obtaining ethics approval and funding. Researcher match means that researchers must assess their qualifications to conduct the study in a foreign country, as well as their understanding of the traditions, values, family systems, socioeconomic issues, attitudes and social policies of the country. Having a gatekeeper who vouches for the study is integral in building web relationships and creating new relationships with others (Johl and Renganathan 2010). For the stigma study, the researchers’ relationships with HIV/AIDS networks in Kenya provided an opportunity for networking with MildMay International, a non-governmental organisation (NGO) committed to building capacity for HCWs in HIV/ AIDS environments. The NGO helped the researchers to access multiple informants and provided transport to research sites. For the WRQoL study, the researchers’ long-standing relationships with UNMU and MU aided in creating new relationships and strengthened existing relationships with affiliated partners in rural and urban Uganda. Speaking the same language and being of the same ethnicity as research participants can influence © RCN PUBLISHING / NURSE RESEARCHER
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 11, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
International research
■■Access individual subjects
■■Data collection ■■Address cultural and
■■Data storage ■■Data analysis ■■Follow-up communication ■■Disseminate findings
Ge ba tting ck
-e n
tr y
ethical issues
Pr e
framework ■■Establish relationships ■■Build trust and credibility ■■Address researcher match concerns ■■Obtain ethics approval
g rin ork Du d w l fie
© RCN PUBLISHING / NURSE RESEARCHER
■■Adapt an ethical
r te rk Af wo ld
During fieldwork Here researchers must contend with ethics, logistics, cultural concerns, data collection, informed consent and access to participants. For the stigma sudy, the researcher (JO) attended a support group meeting for HIV-positive HCWs in Nairobi, Kenya before beginning research in Kisumu. Through active listening and observation, she gained insight into interactions and processes that occur in support groups. This effort promoted acceptance by participants. Furthermore, it informed the researcher’s approach to qualitative interview
Figure 1 Gaining entry into research fields
fie
the degree of cultural competence of a researcher (Rubin and Babbie 2008). Two of the researchers are natives of Kenya while the other two are natives of the US; all four live in the US. To avoid being viewed as outsiders and to address issues of power differentials that are common for studies funded in wealthy nations and carried out in foreign locations (Murphy et al 2006), the researchers talked with residents about local news. The secondary analysis was unique since the research was being conducted remotely without face-to-face interaction. The researchers established rapport with Ugandan and Kenyan partners through frequent email, telephone and digital audiovisual communication such as Skype. Before embarking on international research experiences, students should be trained in research methods and ethics (Pinto and Upshur 2009, Provenzano et al 2010). An ethical framework can help to guide researchers dealing with ethical dilemmas in the field (Pinto and Upshur 2009). Ideally, researchers should collaborate with a faculty member at the institution where they will conduct the research (Murphy et al 2006). For all the studies mentioned in this paper, the researchers encouraged country partners to provide feedback on the relevance of the research instruments before the study began. Additionally, Ugandan and Kenyan faculty members were instrumental in mitigating practical and political issues surrounding ethics approval, which was obtained from the research sites in Kenya, Uganda and the US. The STTI grant and an endowed professorship fund helped to cover local expenses for the stigma study and the WRQOL study. Minimal expenses were incurred for the secondary analysis study. Consulting with family, friends and gatekeepers in host countries provided insight into the average costs of miscellaneous expenses. To avoid being overcharged, the researchers frequently travelled in the company of locals who negotiated to obtain the same prices as those charged to residents.
■■Manage logistical concerns
■■ Collect additional information
■■ Clarify issues ■■ Lay groundwork for future research and collaborations
sessions in the field. The researcher (JO) also built rapport and trust with participants by dressing appropriately, speaking clearly, minimising their use of jewellery and accessories, speaking in local dialects, travelling on local public transport and encouraging participants to use the researchers’ first names. Accessing individuals for the WRQoL study was easier because potential participants were attending planned nursing development workshops. For the stigma study, gatekeepers of HIV/AIDS support groups in Kenya were instrumental in obtaining access to participants. Most participants opted to meet the researcher (JO) at a central guesthouse but whenever necessary, the researcher travelled to meet participants at their preferred sites. Since travel to remote sites can be expensive and time-consuming, creating an interview timetable that provides adequate time for travel to and from research sites is important. Researchers must remember that transaction practices vary globally (Murphy et al 2006). For example, obtaining receipts for transport at the end of each journey may not always be possible. However, funding agencies require documentation accounting for use of research funds. One possibility, therefore, is for researchers to travel with pre-printed, generic receipt books and have vendors sign and justify payment for services rendered. When access to essential informants is denied, researchers can use alternative routes (Shenton and Hayter 2003). In the stigma study, a key person at one hospital demanded copies of November 2014 | Volume 22 | Number 2 31
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Art & science | acute care Nurse Researcher the research protocol for further review by the hospital’s research board. The researcher (JO) was asked to pay additional fees for this. Due to time constraints and the fact that the researcher did not encounter this challenge at other hospitals, the researcher decided to use an alternative route to recruit participants: snowballing and purposive sampling with the assistance of the primary gatekeeper. Once a researcher is in the field, some survey items for studies may need to be refined. For example, cadres identified in the stigma study included the terms ‘staff nurse’, ‘professional nursing sister’ and ‘community health worker’. Subjects who identified themselves as ‘community health registered nurses’ found these categories confusing. In addition, the survey item on annual income proved cumbersome for participants in the stigma study as the item did not specify gross or net. Subjects had to use their calculators to estimate their annual salaries. ‘Monthly gross salary’ was identified as more acceptable. The issue of defining oneself as an ethnic minority is common in surveys designed in the West. Like Kenya, Uganda is a country with diverse cultures. Several participants in the WRQoL study found the following question on the demographic survey irrelevant: ‘Do you consider yourself a member of an ethnic minority?’ Thus, responses to this question were discarded during the final analysis. To avoid such challenges, researchers should pilot test measurement instruments in a small sample of potential research participants. In the WRQoL study, 171 participants completed self-administered questionnaires but only146 surveys were used in the final analysis because of missing values. Missing data was not an issue in the stigma study because the instrument was a one-on-one, semi-structured, face-to-face interview in which the researcher recorded participants’ responses to the questionnaire. The secondary analysis had large missing values and these were adjusted for using advanced statistical methods. It is widely assumed that Western ethics training is applicable to global health experiences (Pinto and Upshur 2009). However, threats to rigour may occur when collecting data because of variations in culture and context. This may hinder executing a research protocol exactly as planned. In one instance in Kenya, the researcher (JO) suggested one participant should attend to a patient’s needs first, but the participant adamantly completed the study. Subjects also frequently skimmed through informed consent documents. 32 November 2014 | Volume 22 | Number 2
When this happens, researchers should reiterate points regarding informed consent by asking a uniform set of simple questions about study risks and benefits (Stenson et al 2010). In rural Uganda, it was apparent that the workshops’ participants required more time to read the informed consent documents. Due to time constraints, the research team provided consent forms at the end of the workshops and encouraged participants to take the documents home to review. Participants who attended the workshops on the second day signed consent forms and then completed the survey instruments. In Uganda, some participants at clinics requested that the researcher leave survey forms with them and return to pick them up at the end of the day. Researchers need to be flexible and receptive to suggestions from participants. Although the researchers lost some control, they felt that it was ethical to have participants attend to patients’ needs first, as well as to have adequate time to read and understand the consent document. To minimise groupthink, the researchers instructed participants not to share answers or discuss their responses. Compensation for participants in research remains a topic for debate (Stenson et al 2010). Murphy et al (2006) suggested that offering US$10 for two hours’ work in a country where the daily wage is US$5 can be coercive. Stenson et al (2010) suggested that alternative forms of compensation, such as food, supplies and other tangible items, may be considered more valuable than cash. They recommended that participants be compensated with items they are unlikely to purchase and which have secondary benefits, such as education, nutrition and empowerment. Once the researcher is on the ground in a foreign country it may be necessary to make some changes to the research plan based on the country context. Thus, when conducting international research, researchers must be flexible and build in some extra time within their research plan in anticipation of the potential for ethics approval modification once in the field. For example, for the stigma study, the researcher (JO) had obtained approval for compensation for each participant of mobile phone airtime valued at US$12. On arrival in Kenya, it became apparent that there are several mobile phone companies so any prior effort to purchase airtime would have been cumbersome and potentially wasteful since the researcher had no way of anticipating the participants’ network providers. Following consultation with partners in © RCN PUBLISHING / NURSE RESEARCHER
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International research Kenya and after ethics approval modification, it was resolved to offer each participant the equivalent of US$12 (KSh1,000). Researchers must also anticipate challenges from common hidden costs, including cashpoints, the exchange of currency and bank fees (Murphy et al 2006). To avoid carrying large amounts of cash in Kenya, the researcher used local mobile banking M-PESA kiosks – a relatively cheap, secure and convenient electronic way to manage cash. Post-entry After collecting data, researchers must contend with the issues of leaving the field, storing and analysing data, and maintaining contact with key individuals. For the stigma study, the researcher (JO) hired a local transcriptionist, trained in protecting research participants. This expedited data analysis, was cost-effective, saved time and ensured accuracy, since the transcriptionist was familiar with local language intonations and expressions. Furthermore, it provided a resident with a job, in an area where such opportunities are often scarce. Data handling and storage in the field can be cumbersome. Materials must be stored in safe places and electronic files must be password-protected. Analysis can be hindered by restrictions placed on measurement instruments by their authors. Instruments for the stigma study and the WRQoL study are available for free and scoring information for the stigma study was easily accessible. However, the researchers could not obtain scoring information for the WRQoL study. Instead, the tool’s developers offered to analyse the data in return for anonymised copies of the data for their benchmarking database. Finally, leaving the field can be emotional for researchers and participants. Participants may solicit from researchers help related to personal matters. In Kenya and Uganda, some participants wanted to know if the researchers could help them to emigrate to the US or assist them financially. It is important for researchers to acknowledge the challenges
presented to them by individuals in the field, while keeping their role as researcher separate. Stenson et al (2010) highlighted the importance of appreciating the contributions of research staff, to maintain the integrity of a research programme. Murphy et al (2006) urged international researchers to identify creative ways to compensate collaborators, including culturally appropriate gifts. If contact information is available, ‘thank you’ cards and follow-up emails are important in maintaining rapport. Re-entry Getting back into the field may not always be necessary. However, researchers should maintain rapport with gatekeepers throughout all the stages of the study, which could assist with re-entry to collect additional information or clarify issues if necessary. For instance, in the stigma study, the researcher (JO) left some documents in Kisumu. The researcher had established and maintained rapport with the gatekeepers, which proved invaluable as they returned the documents to the researcher safely. Providing contact information to participants and voluntary communication between participants and researchers are encouraged. These are integral in sustaining relationships and laying the groundwork for future research targeting vulnerable, hard-to-reach populations (Johl and Renganathan 2010, Stenson et al 2010).
Conclusion Despite the many challenges, conducting international research has significant implications for research, education, policy and practice. International research provides opportunities for building cultural competence, enhancing effective international partnerships and collaborations, and generating knowledge that can inform policy changes. It is imperative that educators use innovative strategies to integrate global healthcare research concepts into the curricula of healthcare professions.
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Conflict of interest None declared
References Global Forum for Health Research (2004) The 10/90 Report on Health Research 2003-2004. GFHR, Geneva, Switzerland.
Opollo DA (2011) Modernization and Contraception in Kenya from 1998 to 2008-2009. Doctoral dissertation.
Pinto AD, Upshur RE (2009) Global health ethics for students. Developing World Bioethics. 9, 1, 1-10.
Johl SK, Renganathan S (2010) Strategies for gaining access in doing fieldwork: reflection of two researchers. The Electronic Journal of Business Research Methods. 8, 1, 42-50.
Opollo JG (2012) Extent Of HIV Stigma Among HIV Positive Healthcare Workers: A Mixed Methods Approach. Doctoral dissertation.
Provenzano AM, Graber LK, Elansary M et al (2010) Short term global health research projects by US medical students: ethical challenges for partnerships. American Journal of Tropical Medicine and Hygiene. 83, 2, 211-214.
Murphy AD, Perilla JL, Jones E (2006) Conducting research in other countries. In Norris FH, Galea S, Friedman MJ, et al (Eds) Methods For Disaster Mental Health Research. The Guilford Press, New York NY.
Opollo JG, Gray J, Spies LA (2014) Work Related Quality of Life of Ugandan Nurses: A Descriptive Study. International Nursing Review. 61, 1, 116-123.
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Shenton AK, Hayter S (2004) Strategies for gaining access to organisations and informants in qualitative studies. Education for Information. 22, 223-231. Stenson AL, Kapungu CT, Geller SE et al (2010) Navigating the challenges of global reproductive health research. Journal of Women’s Health. 19, 11, 2101-2107.
Rubin A, Babbie ER (2008) Research Methods For Social Work. Sixth edition. Brooks/Cole, Cengage Learning, Belmont CA.
Suhonen R, Saarikoski M, Leino-Kilpi H (2009) Cross-cultural nursing research. International Journal of Nursing Studies. 46, 4, 593-602.
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