Reflections on researcher’s position

A researcher’ background and position in a qualitative research project will affect every step of a research project, from choosing what to investigate, to the approaches and questions chosen, to the research encounter and to the communication of the conclusions of the study (Malterud, 2011, p. 38). Hence, researchers may access different but equally valid representations of a phenomenon depending on their position and perspectives (Malterud, 2011, p. 39-40). Reflexivity involves identifying and making explicit the researchers’ preconceptions, pre-study beliefs and motivation brought into the study. It also includes the presentation of previous personal and professional experiences deemed to be of particular relevance for the study. The researcher has to be especially careful of mixing or blurring knowledge embedded in preconceptions with knowledge emerging from systematically obtained data

(Malterud, 2011, p. 40-42). In ethnography, as well as in other qualitative research approaches, the researcher through the role of active participation, functions as the research instrument. The researchers’ influence on the context, including shifting behaviour and conduct, thus becomes central to the analysis (Hammersley and Atkinson, 2007, p. 17).

Being a European looking foreigner and a student at PhD level gave certain

advantages during the fieldwork. It for example generated a certain level of perceived

‘seniority’ that gave me ‘natural’ access to talk to those above me in the hierarchical medical system while being on the ward, such as residents, gynaecologists as well as surgeons visiting from abroad. Also in the communities it may have given me an advantage, as it was fairly easy to access actors from the relevant NGOs and from the health authorities.

Throughout the study, and especially during the participant observation at the hospital, my background as a Registered Nurse (RN) from a gynaecology ward in Norway influenced how I understood pelvic floor disorders, and the ways in which I perceived the care and treatment given to the patients at the hospital. It also played an important role in the interaction with the health care staff at the Fistula Centre. The

nurses may at times have perceived me as ‘one of them’ as we shared similar educational background.

As the Fistula Centre is a training centre, and often accommodates foreign clinician’s whose purpose is to teach, as well as to learn about obstetric fistula treatment, my participant observational role was initially perceived as unfamiliar among the nurses.

It was in fact an expectation that I would teach and share from my knowledge and experience. However, after another round of explanation of the purpose of the method and the research, my role did not seem to be any problem, and the nurses continued to include me in their daily work-activities. During one incidence when the majority of the nurses were taken out of the ward for a workshop, the head-nurse told me to stay behind at the ward together with one other nurse. I perceived this as a sign of trust, and that my presence on the ward was both accepted and in some instances perceived as helpful. During another incidence when an important donor was visiting the ward, I observed how the ward was made even cleaner and nicer than on ‘normal’ days.

This also confirmed that my presence on the ward did not substantially influence the

‘natural setting’ of daily routines and activities at the ward. I assume that social desirability bias to some extent may have influenced the nurses to perform best practice in my presence. However, it may have been somewhat reduced by the fact that the nurses were informed about the focus of my study. The fact I stayed on the ward over an extended period of time possibly also limited such potential bias.

The interactions with the women on the ward were to a larger degree influenced by my ‘otherness’. On one side they may have regarded me as part of the formal health system, as I was wearing a nursing uniform and was performing nursing activities alongside the other nurses. On the other side, I assume that they perceived me as a

‘ferrenji’ (a light-skinned foreigner), which comes with common preconceptions of being an ‘expert’/’specialist’ and/or wealthy. Although I was clearly regarded as an outsider, it is likely that speaking with the local language, although at a very basic level, created a closer contact between me and the patients. At the ward as well as during the interviews with the women, being female was assumed an advantage for

my main research assistant and myself, since the topic in question was highly gender specific and sensitive. Our somewhat young age (both in the beginning of our 30ties) compared to the majority of the informants, and the fact that none of us had yet given birth, might have limited the women’s sense of connecting with us, especially the older informants.

Although the research assistants’ and my own background surely influenced the encounters with the women and the way in which they shared their experiences with us, the research assistant and I perceived the large majority of the women to be surprisingly open. This perception was based on my previous experience of interviewing women with various degrees of urinary incontinence in the same area during the DABINCOP fieldwork in 2011. The women with urinary incontinence were extremely shy in the interview situation, and many spoke with such a low voice that it was difficult to hear what they said. An important difference between the two groups is that the condition of prolapse was reported as easier to hide compared to urinary incontinence. Another important difference is that the women with prolapse, at the time of the interview, had already started to open up about their condition with their fellow sufferers through their role as participants in the ‘prolapse-campaign’.

During the follow-up visits, although removed from the hospital setting, the women most likely associated us with the hospital. However, the appreciation that they expressed in relation to our visit and their willingness to continue to share their experiences with us, indicated that a certain level of trust had been established during the hospital stay and the previous interview. During our visits to the communities, the research assistant and I moreover strove to be sensitive towards local social and cultural norms, e.g. by following the socially acceptable dress code for women in the area and to greet people in a socially acceptable and respectful manner.

During our visits to the Holy Water sites, both in the communities and in Gondar, my

‘outsider’ appearance gained some attention and people approached us with

questions. Often these were men asking for health advice, assuming that I as a

‘ferrenji’ was a physician or another kind of specialist.