Validity and relevance of the study

Qualitative research, like other research, employs strategies for assessing and questioning the validity of their studies (Malterud, 2001). While the internal validity relates to whether the study investigates what it is meant to, the external validity relates to what other contexts the study findings may apply to. Mays and Pope (2000) suggest several ways of improving validity in qualitative research, however, they, as well as Malterud (2001), emphasize that assessment using concrete criteria is not a straightforward matter, but requires continues process of judgements and assessment.

Triangulation involves the comparison of results from different data collection methods or data sources, with the aim of finding corresponding and diverging

patterns to sustain an overall interpretation (Mays and Pope, 2000). The assumption is that weaknesses in one method to some extent may be compensated for by strengths in another, which may improve the comprehensiveness and reflexive analysis of the data (Mays and Pope, 2000). Ethnographic studies imply an “inherent triangulation”, as one by definition observes, participates and speaks to different people, commonly from the full spectre from informal talk to formal qualitative interviews. Hence a substantial degree of methods and source triangulation normally takes place over an extended period of time (Hammersley and Atkinson, 2007).

The four months spent in the research area during 2011 had made me somewhat familiar with the culture, conduct and the physical environment in the study context.

Having spent a total of one year in Ethiopia during the present PhD project, increased my cultural and language competence in the research area which obviously has had an important impact on my ability to make sense of the data collected.

Inclusion of different categories of informants broadened the knowledge of the phenomenon in question and gave insights from differently positioned actors, such as

women with different backgrounds and various categories of health workers, which added important contextual information and nuances to the material. The inclusion of local health workers proved extremely useful for my understanding. Continuous informal talks with a variety of people throughout the time spent in the field added to the understanding of both the topic in question and the socio-cultural context in which the study took place.

Conduction of the focus group discussions (FGDs) towards the end of the fieldwork provided a very good opportunity to scrutinize my study findings with a similar group of informants. We did not encounter substantial contradictory findings through the FGDs, compared to the already gathered material. Rather, the discussions seemed to confirm the preliminary conclusions, but provided additional information about common patterns of health care behaviour in the research area, and thus strengthened the previous material. For example, relatively few informants elaborated on or admitted that they had sought help at local healers or carried out spiritual ceremonies for their health problem during the individual in-depth interviews, although we suspected that it was a common practice in the area, and thus probed the women on the topic. The women in the FDG to a large degree confirmed that it was common to seek spiritual help when facing illness, and not to speak openly to others about it as it was religiously not accepted by the Orthodox Church and hence shrouded by secrecy.

This explained the seeming reservation among our previous informants to share the full extent of their health care seeking strategies and experience.

Another way to improve validity of a qualitative study, according to Mays and Pope (2000), is through respondent validation. This involves comparing the researchers’

interpretation to that of the study participants’, and to incorporate the study

participants’ reactions into the study findings (Mays and Pope, 2000). A respondent validation with the informants themselves did not take place, however the FGDs with women from the same area and condition validated to a large degree the findings for paper II, as mentioned above. The follow-up interviews constituting the findings for paper III implied an important opportunity to clarify earlier mentioned issues, for

example related to health care seeking. Prolonged engagement, persistent observation and follow-up of many of the informants over a longer period of time moreover allowed for a certain level of trust to be built up between the informants and myself, as well as with the health care workers at the hospital. Working closely together with the main research assistant during the translation-process of the complete material was also vital in the process of continuous questioning and validation and clearly enhanced my understanding of the women’s stories.

Mays and Pope (2000) furthermore emphasize the importance of presenting a clear account of the process of data collection method and the analysis in qualitative research. The different phases of the present fieldwork allowed me to ‘step back’

from the field to carry out preliminary analysis of the material, and to discuss emergent findings with my supervisors, the main research assistant and the research collaborator at the hospital before starting the next phase of the fieldwork. During the more rigours analysis process of the material after leaving the field, I had close communication with the main research assistant which allowed for clarification of particular parts of the material. During the write up of the articles, several of my Ethiopian research collaborators were involved in the process as co-authors, which further limited the possibility of serious cultural or contextual misunderstandings in the interpretation and presentation of the findings.

Another important way to enhance the validation process in qualitative research is through a ‘deviant case analysis’. This involves, according to Mays and Pope (2000), to search for and discuss elements in the data that contradict the emerging

explanation of the phenomenon under study. Through the process of analysis, I tried to keep an open mind, and made efforts throughout the coding and categorization of the material to include and display any kinds of experiences related to the topic, to secure that the findings from the study were as close to the stories that had been communicated to me as possible. It was however not difficult to encounter variations in the present study material, e.g. experiences described by single women revealed hardships of a very different and more severe kind compared to married women due

to the lack of possibilities to get assistance in connection with the physical

demanding daily chores. I also made strong efforts to avoid emphasizing the stories or experiences that appeared more ‘exotic’ based on my own curiosity or interest.

Due to strict word constraints in the medical journals for paper I and III, the presentation of the findings, as well as the description of the research methods employed, were however restrained.

Although an important aim of research is to produce information that can be shared and applied beyond the study setting, the relevance of the findings from a qualitative study beyond the research setting should not be exaggerated, as it most and foremost produces descriptions, notions or theories applicable within a specified setting (Malterud, 2001). A thorough presentation of the contextual background of the study is however vital to clarify for which situations or settings beyond the study setting the findings may provide valid information (Malterud, 2001, Mays and Pope, 2000).

As prolapse is a topic yet limited researched in resource-constrained settings, there is scarce knowledge to compare the findings of the present study with. This however reinforces the initial aim of adding to existing knowledge within the topic-area.

Choosing women from two different districts of rural or semi-urban locations, and who varied in age and length of experienced symptoms, we attempted to ensure that the findings included different factors that might affect variability in experience among women living with prolapse in the study area. Through detailed descriptions of the context in which the women live, the reader should to some extent moreover be able to judge the relevance of the findings for other similar contexts. As the majority of the women included in the study lacked formal education and lived in rural areas, and thus represent the large majority of women in Ethiopia, it is moreover likely that the findings from the present study has relevance and transfer value to similar settings within Ethiopia, but also to some extent to other resource-constrained settings that experience substantial constraints in terms of education, poorly developed or equipped health services, early marriage practices etc.