CHAPTER THREE

IN-DEPTH INTERVIEWS

This chapter focuses on the use of in-depth interviews as

an applied qualitative method in drug use studies. It
begins with a brief overview of the technique and
continues with a description of the various steps involved
in carrying out an applied qualitative study using the in-
depth interview method.

3.10: Overview

3.11: What is an In-Depth Interview?

An in-depth interview is a qualitative research technique that allows person

to person discussion. It can lead to increased insight into people's thoughts,
feelings, and behavior on important issues. This type of interview is often
unstructured and therefore permits the interviewer to encourage an
informant (respondent) to talk at length about the topic of interest.

The in-depth interview uses a flexible interview approach. It aims to ask

questions to explain the reasons underlying a problem or practice in a
target group. You can use the technique to gather ideas, to gather
information, and to develop materials for drug use interventions.

3.12: Use of In-Depth Interview in Drug Use Studies

One effective way to understand the reasons underlying problem behaviors

is in-depth analysis. In drug use studies, areas in which the method can be
used include:

! In pilot studies to generate ideas.

! To obtain greater depth of information on a topic of interest as a

supplement to data received from other methods, e.g.,
structured questionnaire.

! To evaluate the impacts of interventions on attitudes or beliefs.

3-1
This section will consider only how in-depth interviews are used to gather
data to prepare for interventions.

3-2
3.20. Steps in Using In-depth Interview to Study Drug Use Problems

The activities involved in using in-depth interview to study drug use

problems can be organized into a series of steps. These are summarized
below. A detailed discussion of each step follows the summary.

TABLE 3.1: Summary of Key Steps in Conducting In-depth

Interview

Step 1: Plan how you will conduct the in-depth interviews.

Step 2: Decide who your respondents will be.

Step 3: Prepare interview guide for each category of informants.

Step 4: Select your interviewers.

Step 5: Train the interviewers.

Step 6: Conduct the actual interviews.

Step 7: Analyse the data.

Step 8: Write a report and recommend intervention(s).

3.21. STEP 1: Plan How You Will Carry out the In-depth Interview

Once the decision to use in-depth interview has been taken, very important
planning decisions and preparations are needed. These include designing
the study, identifying the target group, preparing for the fieldwork, and
collecting and analysing the data.

a. Consider the Need for a Resource Person

Because the technique may be new to most health oriented professionals,

one of the first planning decisions to consider is the need for a resource
person, particularly if the investigator is not confident enough with the
application of the method. Other things to consider before you decide to

3-3
seek the assistance of a resource person are the size of the study and the
resources available to it.

3-4
In a small exploratory study with limited resources, you could rely on a
colleague who had used the method before. However, in a big study to
ascertain the reasons for some observed problem behaviour, you may need
the assistance of a social scientist who is well experienced in the actual use
of the method.(See Section 2.10 for more tips on qualities to consider when
in need of a resource person).

b. Role of a Resource Person

Essentially, the role of any resource person at this stage will be to assist in
planning the technical details of the study. This will include:

! how to obtain the study informants;

! development of interviewing guides;

! how to proceed with the field work;

! training of interviewers and other field staf;

! guidance in subsequent analysis of the field data.

These aspects of the study are very important, and such professional
support needs to be seriously considered if the principal investigator is not
too confident about the method.

3.22. STEP 2: Decide Who Your Informants (Respondents) Will be

Identifying respondents from whom you can obtain the information you
need is a very important part of the study since the sources of information
affects the quality of data obtained. You must therefore identify key
informants who can provide useful information for the study.

a. Determining Who to Select for the In-Depth Interviews

The first thing to bear in mind is that in-depth interviews take much more
time than structured questionnaires. It is therefore not usually practicable
to interview a large sample. A typical study might include 3-4 interviews
with respondents in each of 4 subgroups of interest, for a total of less than
20 interviews. To account for the small sample size, those selected for the
in-depth interview must be people who are well informed about the issue to
provide relevant information. Usually informants are selected for in-depth
interviews in a purposive manner, that is, people with specific
demographic/social characteristics are chosen to represent a defined
subgroup.

3-5
This involves identifying individuals from the target groups who are and
must be knowledgeable about the study topic. Depending upon the nature
of the problem and composition of the target population, respondents are
selected from various identifiable subgroups. Respondents selected must
be fairly representative of the various groups in the study population for this
technique to be useful.
b. Selecting Informants: Some Examples

Let us consider a study about the overuse of antibiotics in the treatment of

ARI in children. After deciding to use in-depth interviews, a study team may
have identified the following target groups:

! prescribers working in primary, secondary, and/or tertiary health

care facilities;

! dispensers working in these same health care facilities;

! mothers with children under the age of five in the community;

! operators of drug outlets in the private or informal sector.

The following example (Figure 3.1) describes two ways in which participants
could be selected to represent these target groups.

3-6
Figure 3.1:Examples Showing How Respondents May Be Selected

Example 1: To identify representative prescribers in public

health facilities:

! List the names and locations of all health facilities in the

district separately according to levels, i.e., all community
clinics, all health posts/centers, all district hospitals.

! Select a small number of facilities in which the interviews

are to be conducted, e.g., 2 community clinics, 2 health
centers, 1 hospital.

! In each facility, choose one health worker in each category

to be interviewed, e.g., village health worker, officer-in-
charge, paramedic, dispenser, or pediatric specialist.

If the information from the selected respondents is not consistent,

additional facilities and respondents can be chosen in the same way until
the reasons for the inconsistency are understood.

Example 2: To identify representative mothers of children under

the age of five recently treated for ARI:

! Contact the selected health facilities in the study district.

! Get a list of children under the age of five treated for

recent episodes of ARI (ideally within two weeks
preceding the study to enhance recall by mothers who
will be interviewed).

! Decide on reasonable number of mothers to be

interviewed, e.g. 2 mothers treated at each of five
facilities.

! Contact the mothers in their homes and arrange

interviews.

If it is not feasible to identify mothers from clinic records, it may be

necessary to draw the sample in the community. Village elders or local
administration after have lists of families and family members. Families
should be visited until two recent cases of ARI are identified.
c. Hints for Selecting Informants for In-Depth Interviews

Some hints to consider when making your final selection of key informants
are:

! The informants should be unknown to the interviewers, if at all

possible, in order not to increase the likelihood of their giving
biased responses.

! They should not have previous knowledge of the specific issue of

study.

! A conscious attempt should be made to select different

categories of individuals in each target group, for example, by
age, gender, status, education.

3.23. STEP 3: Prepare an Interview Guide for Each Category of

Respondents

The guide consists of a list of questions or topics to be discussed by

interviewers with respondents in the field. The quality of data obtained
depends to a large extent on the quality of questions in the guide. A good
guide uses general, non-directive questions or phrases instead of
direct questions that may end up in "Yes" or "No" answers. The task
of the investigator or team of investigators involves reviewing the study
topics to develop questions that will yield relevant responses. Following are
suggested stages in developing the interview guide:

a. Framing the Questions

1. List the most important topics to be explored in the study.

For example, for a study investigating the overuse of antibiotics in the

treatment of ARI in children, we could list some of the specific topics for in-
depth interviews with health workers:

! which particular antibiotics are being used;

! symptoms associated with perceived need for antibiotics;

! reasons for prescribing antibiotics for the common cold;

! reported patient preference for drugs;

 ! sources of information about antibiotics.

2. Identify relevant subtopics for each of the study topics

Each major topic can be broken into specific subtopics that can be explored
during the interviews. For example, in relation to reasons for prescribing
antibiotics to treat common colds, we can list the following sub-themes:
 beliefs about respiratory infections;

! efficacy of antibiotics in treating infections.

3. Make a draft of possible questions that could be explored with

respondents about these sub-topics.

4. Check each question against the overall study questions and

take out those that are not needed to answer one or more of
the study questions.

5. Check the questions again to ensure that they can help initiate
discussion.

Ensure that your questions are:

! clear and unambiguous;

! simple and easy to understand;

! reasonable and within the experience of the targeted

respondents.

b. Construction of Probes

When writing the guide, build in useful "probes" to assist the interviewer.
Probes are devices used to prompt a respondent to speak further
when an initial question fails to elicit the desired information.
Suppose in our antibiotic illustration the following question is asked of a
prescriber:

What would your reaction be if you were advised by the District

Medical Officer to stop the use of antibiotics in the treatment of
ARI in children?

Answer: Well, I guess we'll have to wait and see what happens
when the time comes.

Here the respondent avoided answering the question. If his answer is

accepted, his attitude about a policy against the use of antibiotics in
treating ARI will not be known. It is helpful to anticipate this difficulty, and
to construct "probe questions" in advance to cater for these situations.

An example might be:

How would you feel about the DMO issuing such a directive?
The creation of appropriate probes brings a measure of control to a
potentially haphazard form of questioning.

c. Sequence of Topics

In general, the order of topics in in-depth interviews is never rigidly defined.

Rather this is left at the discretion of the interviewer and is determined by
the flow of the discussion. This is one of the reasons why interviewers need
to be well trained in the art of interviewing.

Design the guide in such a way that similar types of information will be
elicited from all respondents. However, the particular phrasing of questions
and their order or sequence may be re-defined to fit the characteristics of
each interview.

Example of Interview Guide

Figure 3.2. shows a list of questions that may be asked in an in-depth

interview to investigate the use of antibiotics by prescribers in treating ARI
in children. The interview may not necessarily follow this order. More
examples of in-depth interview guides are provided in annexes.
FIGURE 2: Example of Interview Guide

Use of Antibiotics in the Treatment of

common cold (ARI) in Children.

Interview Guide for Prescribers

Introduction: Self introduction, name and general affiliation

Purpose of Interview
We are aware that common cold (ARI) is one of the common health
problems of children in this community. We are interested in knowing
your views about this problem and how it is managed. It will be
appreciated if we could spend some time together to discuss this issue.

Interview Begins

Clinic Experience
How long have you been working as a (doctor, paramedic, etc.)?
How long have you been working at this clinic?
How many patients do you see in a day?
How many of these patients are under the age of five?

Diagnosis
Could you please describe how respiratory infections present
themselves in children in this community?
How do you decide on severity of case?
What are some of the symptoms of severe respiratory infection?
Is it hard to recognize these symptoms?

Treatment
How do you usually treat mild respiratory infection in children?
Do you always treat coughs this way or do you sometimes treat them
differently?
If yes: How do you decide on how to treat a cough?
Do mothers sometimes ask for particular medicines?

Use of Antibiotics
When should someone prescribe an antibiotic for a child with common
cold?
Which antibiotics are the best to prescribe?

and so forth
3.24. STEP 4: Select Your Interviewers

The success of an in-depth interview depends in large part on the qualities

of the interviewer. Much more communication skill is required than would
be needed for administering ordinary questionnaire interviews.

The role of the interviewer is to keep a discussion going by asking useful

questions until he or she gets an appropriate response. This demands
certain qualities in those selected for the task. The following qualifications
are useful to consider:

! Formal training in social science or interviewing is an advantage

though not a pre-requisite.

! When social scientists are not available, people with secondary

education in health- related areas such as nurses and community
development workers or social workers with some experience in
interviewing may also be suitable.

Good interviewers are people who easily gain peoples= confidence and
cooperation, speak clearly, and are good listeners. Additional qualities to
consider are:

! knowledge of drug use issues;

! self confidence;

! ability to establish rapport;

! confident but not pompous;

! unassuming personality;

! politeness;

! articulate enough to prompt respondents to talk.

3.25. STEP 5: Train the Interviewers

Training provides an opportunity to prepare the field team for their task. All
field workers involved in a study attend a common training session so they
can start with a common understanding of study objectives and procedures.
Even experienced interviewers need to be trained, since each study will
have its unique objectives, target groups, and study instruments.

a. Duration of Training

Training should be long enough to allow all aspects of the study to be

tackled before the actual field work. The length of time may vary depending
upon the size of the study and calibre of the field team. In general,
however, this may take two to three days.

An ideal location free from interference with the daily work routine of the
field team must be secured for the training sessions. In order not to disrupt
the sessions all materials and provisions, including snacks and lunch, should
ideally be provided on site.

b. Training Sessions

At the beginning of the training, materials such as the study guides,

protocols, and handouts should be given to the interviewers so that they
can study them and raise any general queries during the training. The
trainer must explain and discuss these materials with the interviewers. The
discussion of each material should be allotted reasonable time to make it
effective. The trainer should encourage a friendly and conducive
atmosphere for free exchange of comments and questions.

The training program can be organized in stages with specific objectives.

Prepare an agenda before assembling the interviewers. Sessions will be
needed on both theoretical and practical aspects of the study. The
theoretical aspects cover topics including:

! outline of the goals and objectives of the study;

! overview of in-depth interviews;

! how to conduct in-depth interviews, i.e., starting, moderating,

and ending the
interview;

! how to take notes during interviews;

! outline of possible implementation problems;

! how to analyze the data and write a report.
The practical aspects of the training involve:

! role plays;

! pilot testing.

Role Play:

Provide an opportunity for each interviewer to role play the interview to gain
experience before going to the field. Such role plays are also a great help
in evaluating the effectiveness of individual interviewers. Go over the
interview guide as many times as there are questions and comments raised
by interviewers.

Pilot Testing

Before the actual fieldwork, you should plan to conduct a pilot test in a
group similar to the target group in terms of study characteristics. This
exercise affords an opportunity for the investigator and the study team to
evaluate the appropriateness of the interview guides. It also enables
interviewers to put into practice the skills they have learned before the
actual interview.

After the pilot test the study team should meet to discuss the experience in
the field. Problems relating to the appropriateness, clarity, or ambiguity in
the use of the guide, as well as others relating to respondents and the study
environment, can then be fully discussed.

Discuss any issues of translation of guides and/or notes at the training

sessions. To avoid later problems, ensure that all translations are
thoroughly reviewed before the group moves into the field.
TABLE 3.3: Tips on How to Conduct an In-depth Interview

The "Dos"

! Begin interview with a friendly and familiar greeting.

! Listen with attention to capture every piece of
information from respondents.
! Explore key words, phrases, idioms, terms as they occur
in the discussion.
! Listen to impressions, topics avoided by informant,
deliberate distortions and misconceptions or
misunderstandings. Take prompt action to explore each
of these. Where appropriate, use "probes."
! Ensure a natural flow of discussion by guiding informant
from one topic to the next.
! "Play dumb"(be silent) to give the respondent plenty of
room to talk.
! Be open to unexpected information.

"The Don'ts"

! Influence or bias responses by introducing one's own

perceptions or asking leading questions which
encourage a particular response.
! Move too quickly from one topic to the next
! Interrupt the informant.
! Do not mislead about the subject matter in order to
obtain information.
c. Outline Procedures for Subsequent Data Analysis

You can use the opportunity provided by the field test to outline procedures
for the subsequent data analysis. This involves the following steps:

! Create teams (about two for this purpose) to discuss the

questions to be answered.

! Review notes of the interviewer=s observations.

! Review each sub-theme in the interview guide for all groups of

respondents, e.g., prescribers, mothers.

! Write out key findings from each subtopic for subsequent

analysis. This may include the following:

- demographic and socio-economic characteristics of this

category of respondents;

- major points of agreement across all interviews;

- substantial points of disagreement between interviews;

- any conclusions or implications for the design of an

intervention.

- group's suggestions on what to do to reduce overuse of

antibiotics.

3.26. STEP 6: Conduct the Actual Interviews

After completing the pilot test, you are ready to start the actual data
collection. Before moving into the field, however, you need to make
preparations to ensure that the field work proceeds well without any
logistical problems.

a. Preparing for the Interviews

Preparations should include the following:

The target respondents must be contacted and a definite appointment

made with them before the actual interview. It is usually
best for interviews to be held in a neutral place away from
any health facility or the respondent=s home where
distractions are likely. Make sure that respondents will be
available at the scheduled time.
 If the interview process will involve travel by the field team,
arrangements for transport must be made early to ensure
that the team arrives at the location on time on the day of
the interview.

Besides identification cards and letters of introduction, interviewers

should check to ensure they have all that is required in the
field. This may include: interview guide, pen/pencil,
notebook, tape recorder, batteries, cassettes, snacks, and
water.

b. Conducting the Interview

On the day of the interview, the interviewer should arrive early to ensure
that all arrangements are ready. When both interviewer and informant are
seated, the interview can proceed as follows:

1. Introduction

The respondent must be made to feel completely at ease and

uninhibited in order to make the interaction enjoyable. In his/her
introduction, the interviewer should:

! introduce him/herself and affiliation;

! explain the general purpose of the interview to the informant

(e.g., for prescribers: to investigate the treatment of ARI in
children; for mothers: to find out how ARI is affecting children in
the community.

! impress upon the respondent that his/her opinion is important.

This can be repeated during the interview. People enjoy
expressing their opinion about an issue once they are assured
that it is important and legitimate.

! ask informant to introduce him/herself;

! establish rapport and assure the informant of the confidentiality

of the interview.

2. Interviewing

The interview is directed at understanding the issues outlined in the

guide. Begin with less sensitive issues, and move to specific issues
when the informant is sufficiently relaxed.

Remain alert to both verbal information and non-verbal behavior. If

 necessary, the respondent may be allowed to attend to office or home
distractions during the interview. The interviewer can take advantage
of such breaks to read his/her notes or check the guide to ensure
adequate focus of the interview. Watch for time constraints on the
part of respondent and apologize for time taken, with assurance to
finish the interview on time.

The interviewer should also try to adopt techniques to persuade the

respondent to:

elaborate on points, e.g., "What happens next? Can you please

elaborate?"... etc.

clarify issues: "What year did you join this clinic?"

focus on new dimensions of the issue: "Can we talk about other drugs
used apart from penicillin?@

3. Wrap-Up

The interview should be concluded by thanking the respondent and

allowing a few minutes for free discussion. Once the interview is
formally completed, the interviewer should:

! Go over his/her field notes quickly to make any on-the-spot

corrections and seek necessary clarifications before leaving.
More complete notes can be made at a later time.

! If a tape recorder was used, check and label tapes before

departing the interview site. A new tape should be used for
each interview.

c. Managing the Field Data

The data from each interview must be managed appropriately to facilitate

subsequent analysis. The following tasks are involved:

1. Field editing

At the end of each interview, interviewers should review their notes

and verbatim reports to make sure that they make sense in relation to
the study questions. Comments or any observations made during the
interview can also be added or clarified.

Before leaving the field, interviewers should complete short

summaries of the discussion, ensuring that any additional notes on
 the interview are included.

2. De-briefing

At the end of each field trip or on a regular basis during a long study,
the field supervisor or study coordinator should interview the
interviewers to find out their experiences in the field. This de-briefing
should cover any problems encountered in administering the guide as
well as any new themes or findings from the field. While the field
work lasts, it is possible to make changes in the guide to incorporate
new ideas. Irrelevant questions should also be removed from the
guide.

3. Transcribing

If the interviews are taped, the tapes used should be transcribed

verbatim or in summarized form depending upon the purpose of the
study and the experience of the person doing the analysis.
Afterwards, the points that are important to the study topic should be
underlined. This material should then be reconciled with field notes
and comments of interviewers.

3.27. STEP 7: Analyze the Data

Data analysis begins with the field note-taking of the interviewers. As a first
step, therefore, the study coordinator must ensure that all field data
including notes, comments, and recordings (if any) are recovered from the
interviewers.

The analysis can be done by hand or by computer depending upon your skill
and the resources available to you. Most in-depth studies can easily be
analyzed by hand though there are various computer programs that have
been developed to assist this process. The assistance of an experienced
resource person is especially important during data analysis.

a. Analyzing the Data

Many different strategies have been developed for analyzing the data from
a series of in-depth interviews. A simple way of approaching the analysis
involves the following steps:

1. Categorize interview material into various sub-topics.

This is commonly described as the cut and paste process, and involves
sorting out notes and transcriptions into the broad topics or sub-topics
used in the guide, or adding any new themes from the interviews. For
example, suppose during an interview with a prescriber the question is
asked "How do you usually treat severe respiratory infection in a
 child?" Besides talking about drugs, the prescriber may mention
problems mothers have in paying for treatment. Such information can
be "cut and pasted" under a sub-topic, "Affordability of Treatment."
This procedure ensures that "scattered pieces of information" on the
same sub-topic are put together for a complete review.

2. Label each category using appropriate headings.

For example, under reasons for prescribing antibiotics, responses may
include delays in reporting for treatment due to inability to pay,
multiple health problems, difficulty in monitoring patient compliance,
patient expectation, and a pill for every illness. These categories of
response can be assigned labels such as economic, social-cultural, and
so on. For example, "patient expectation" and "a pill for every illness"
can be put under socio-cultural reasons. This step is very useful for
intervention design.

3. Describe and interpret the major findings

Analysis consists of considering responses in each topic as group, and

drawing interpretive conclusions about commonly held beliefs,
attitudes, or opinions. Implications for interventions should always be
considered. You can also report findings by the proportion of various
sub-groups interviewed giving their reasons under each category, the
apparent strength with which certain attitudes are held, or issues on
which there is substantial difference of opinion..

b. Using a Data Sheet for the Analysis

Sometimes a data sheet can be used to organize the analysis. A data sheet
lists the major topics and sub-topics of the interview guide in order to record
responses in a logical manner. A data sheet for a health provider=s
interview, for example, may contain the following categories:

Personal Data of Informant: i.e., sex, age, education, etc;

! Common Presenting Complaints at Out-Patient Clinics;

! Drugs Used in Treating ARI;

! Factors Influencing the Decision to Use Antibiotics;

! Cost of Treatment;

! Dispensing Process;

! Other Comments, Suggestions, etc.

For each of the sub-topics mentioned, responses of each informant are
recorded from the cut and pasted material assembled from transcriptions,
interviewers' notes, comments, and observations. The data sheets from the
individual interviews can then be combined in an overall analysis as
described above.

3.28. STEP 8: Write a Report and Recommend Interventions

By the time the data analysis steps have been completed, the major
findings of the study should be apparent. It will become clear which data
should go into a final report. The responsibility for the report writing rests
with the principal investigator(s), but if a resource person is involved, his or
her skills are also most valuable at this stage.

a. Outline of Report

The first step in report writing is to develop an outline, bearing in mind the
objectives of the study. Such an outline might contain the following
sections:

! title of study;

! objectives and methods, including data analysis;

! major findings in line with significant broad topics of the guide;

! discussion;

! conclusions;

! recommendations for interventions.

All material from the field should be reviewed together and findings
organized by topic and in conformity with the report outline.

You should bear in mind that the results of a qualitative study using only a
few in-depth interviews are difficult to generalize because of their restricted
scope. However, some form of generalization can still be made, depending
on the type and number of respondents. Hypotheses can also be
formulated on the basis of the major findings, which can then be validated
by use of other more quantitative methods such as structured
questionnaires.