NATIONAL INDIAN HEALTH BOARD Community Health Assessment Focus Group and Key Informant Interviews: Brief Training for Facilitators NATIONAL INDIAN HEALTH BOARD 5/9/18

Topics Community/Tribal Health Assessment Qualitative Data Focus Groups Key Informant Interviews Survey Design Data Analysis Overview

Community/Tribal Health Assessment “A community health assessment is a process that uses quantitative and qualitative methods to systematically collect and analyze data to understand health within a specific community.” -NACCHO

Community/Tribal Health Assessment Purpose of a CHA’s or THA’s: To inform decision making To prioritize public health problems To develop and implement community health improvement plans Meets measures for Public Health Accreditation Quantitative data (numbers and statistics) Example: % adults with diagnosed diabetes Qualitative data (verbal, written) Example: people’s beliefs about diet and exercise Quantitative data (numbers and statistics) can be collected through medical records, surveys, and other existing data sources. Qualitative data (verbal, written) can be collected through surveys, focus groups, and interviews.

Quantitative Data Can provide information on How much, how often, how many and to what extent? Collected through observation and measurement Examples: A1c levels, blood pressure (risk factors for diabetes/related chronic disease) Disease prevalence (how many people have diabetes) Dialysis rates, Death rates (to what extent diabetes causes disability/death) Quantitative data can tell a great deal about the health of your community. Can be primary data or secondary data.

Why Include Qualitative Data? …answers questions that can't easily be asked or answered on a written survey. …supplements the knowledge you can gain from written surveys. …are more open ended, and may address ideas you did not consider. … may show a broader and more in depth picture of what is going on in the community.

Why Include Qualitative Data? Can provide information on How, why, what? Why people behave the way they do Opinions, attitudes or feelings Social/cultural realities What’s important Community readiness to change or adopt new behaviors/policies

Collecting Qualitative Data We are going to discuss two different ways to collect qualitative data- interviews and focus groups. Specifically we will be discussing key informant interviews, which are generally one on one, vs focus groups which thrive on discussion between participants. For focus groups one of the disadvantages indicated is “responders lose anonymity”- meaning that those who participate aren’t anonymous. Although responders lose anonymity in regards to the facilitator and the other participants, when the results are disseminated there will still not be any identifiers- basically, no one will know who responded except for you, the facilitator, the other participants and the researchers.

What is a focus group A focus group is a formal gathering people in the target population (who have background in the area of interest) A way to gather first hand knowledge through qualitative data (opinions, beliefs, attitudes) A guided discussion led by a facilitator (that’s you!)

Why do a focus group? As a way to capture data that can’t be captured through a survey or numbers- more in depth information For the CHA: as part of a mixed mode survey design Mixed mode survey design- Each type of data collection has limitations. Using more than one can give a more complete picture of your Tribe’s health.

Focus Group Protocols Before the Focus Group: Determine how many focus groups you want to run Identify your participants Generate you questions- all facilitators should use the same list Develop a script Select a facilitator Choose a location Secure a note-taker Identifying participants- someone with firsthand knowledge of community (such as community member), select different voices (you may want to separate by type- community members, Tribal Leaders, youth representatives, etc.). Take into account bias- will a community member be as comfortable stating their feelings around a Tribal leader they disagree with? Keep this in mind when ensuring your focus groups are balanced and make people feel comfortable in sharing their thoughts. Generate your questions- Questions should be open ended to spark discussion. Selecting a facilitator- They should not directly oversee the issue you are exploring to prevent bias, however they should be knowledgeable in the topic. Choosing a Location- choose somewhere quite with no interruptions.

Focus Group Protocols Conduct the Focus Group Bring Materials Arrive before the participants to set up Introduce yourself and the note-taker Conduct the Session Materials include notebooks/computers or tape recorders to record proceedings A flip chart paper if there is no white board Focus group list of participants Focus group script or facilitator guide Name tags Watch or clock

Focus Group Protocols Conducting the Session Guidelines: Introduce yourself and give an overview for the purpose of the focus group Collect consent if necessary Set a positive tone Make sure everyone is heard; draw out the quieter group members Probe for more in depth answers Monitor your questions and the time closely (note-taker can help) Don’t argue with a participant Thank participants at the end and share next steps and how data will be used If you are using a facilitator guide, place probing questions after any yes/no questions.

Focus Group Protocols Facilitator’s role: Guide discussion Keep people on task, but don’t cut them off when they are sharing Don’t impose your opinion- remain neutral Ask question the same way each time. Don’t try to lead people or insert your own inflection If asked to clarify a question, make sure your explanation doesn’t change the meaning Do a mock run through with all the facilitators to make sure you are all asking the question in the same way Remaining neutral includes body language and facial expressions, tone of voice, anything that can be interpreted as judgmental of a response. If someone participating states an opinion that makes others uncomfortable, reinforce that this is a safe space while making sure you are not judging the statement. You can correct misinformation but do so in a way that does not shame the person, and use your judgement on if it is necessary- you don’t want myths being spread, but you also shouldn’t tell people they are wrong if it is unnecessary since this may keep them from sharing openly in the future.

Focus Group Protocols Note-taker’s role Observe what is happening in the room such as Record the meeting audio or through video Responses Body language Anything that stands out in the focus group Record any questions that facilitator cannot answer during the session for follow up Take note of any question the facilitator asks that confuses participants so that your focus group can be improved in the future

Sample Script for Facilitator Welcome and thank you for coming. We are conducting this focus group to learn more about [topic]. You have been invited because [why you chose the participants]. Your views on this are very important and will be used to gain a better understanding of [topic]. Before we get started, [insert statement about consent]

Sample Script for Facilitator Ground rules: There are no right or wrong answers We want to hear what you think Its ok to disagree with something that is said, but please respect others You don’t have to respond to anything if it makes you uncomfortable Nothing you share is unimportant or silly This should be a discussion- feel free to talk to one another

Some Additional Tips Provide participants with name tags, paper, and pencils, etc. Allow participants to introduce themselves prior to the session. You may want to keep introductions to first name and age to keep each participant’s identify somewhat confidential

Focus Group Protocol After the Focus Group Facilitators and note-takers should write a quick summary of their impressions. Data will be analyzed by you or someone else. Report is written, usually for dissemination or program guidance. More information on how data will be used after collection will be shared later in this presentation.

What is a Key Informant Interview Key informant interviews are qualitative in-depth interviews with a small number of people who know what is going on in the community. Examples of participants include Tribal leaders, community members, medical or public health providers, etc. A way to gather first hand knowledge through qualitative data (opinions, beliefs, attitudes) from people who have knowledge of the community’s health. Can be by phone or in person Generally ask probing questions Key informants should be carefully selected, as you will want to choose people with insight into the Tribe. Tribal leaders, community health workers, and other people with knowledge of the Tribe’s needs and health issues are good choices.

Why do a Key Informant Interview You want to get in depth information from a few people with connections to the community. To understand the community’s motivation and beliefs. Interviewees may be able to generate recommendations. Interviewees can guide the discussion towards what is important to them and their community.

Key Informant Interview Protocols Before the Key Informant Interview: Steps are generally the same as for a focus group Remember that key informants are often knowledgeable on the topic Key informants should be carefully selected Facilitators should be knowledgeable on the topic This may be conducted in person or by phone. Set up the meeting accordingly Conduct the Session: The facilitator may or may not act as the note-taker Be prepared with knowledge about the topic- you may need to lead the discussion or ask more probing questions than a focus group After the Key Informant Interview: We suggest having an official note taker.

Key Informant Interview Protocols Facilitator’s role: Guide discussion Keep people on task- but don’t cut anyone off when they are sharing! Don’t impose their opinion- remain neutral Ask question the same way each time. Observe your interviewees responses Take notes (whether or not you have a note-taker) Record the session

Sample Script for Facilitator Welcome and thank you for coming. We are conducting this key informant interview to learn more about [topic]. You have been invited because [why you chose the participant]. As a [community leader, health provider, etc.] your views on this are very important and will be used to gain a better understanding of [topic]. Before we get started, [insert statement about consent]

Sample Script for Facilitator Ground rules: There are no right or wrong answers We want to hear what you think You don’t have to respond to anything if it makes you uncomfortable Nothing you share is unimportant or silly

Sample Script for Facilitator Some Additional Tips: Ask the most important questions first in case you run out of time Don’t move to a new question prematurely Don’t get stuck on a question the interviewee may not want or be able to answer

Survey Design- Understanding the Questions You’re Asking What might impact results? Moderator Bias: Moderator’s facial expression, body language, inflection, or the way they ask a question can influence the way an attendee responds. Trying to remain neutral and asking questions in the same way each time can minimize, but not fully prevent this bias Bias means that the answers you are getting are not an accurate reflection of the community or participant. A number of factors can cause bias, but some of the main causes are discussed here so that you can avoid this as a facilitator. Moderator bias is when the way you respond, whether intentional or not, skews how respondents see the question or feel like answering. Don’t do this!

Survey Design- Understanding the Questions You’re Asking What might impact results? Method Error: The way you ask the questions If there are differences between the way focus groups/key informant interviews are run, this can influence the data collected. Following procedures and asking questions the same way each time can reduce, but not fully prevent this bias. If you do things differently each time, respondents will react differently. Because they are having a different experience, the results are not reliable across the board. Although you cannot avoid this as qualitative analysis supports discussion, and particularly for focus groups, other group member’s responses may change the experience, the more similarly you run each session, the more you can minimize bias.

Survey Design- Understanding the Questions You’re Asking What might impact results? Informant Bias: Respondents may give the answer they think the moderator or group wants to hear. They may not give information if they are embarrassed by a topic. You should encourage participants to think of this as a safe space where they can give an honest answer without a negative impact. By encouraging openness you can reduce, but not fully prevent this bias. Informant bias is one of the most difficult to prevent as you cannot force someone to feel comfortable sharing, and they may particularly feel uncomfortable if they feel their response “goes against the grain” or will be perceived negatively. You want to emphasize that this is a safe space, and in a focus group, try to minimize respondents arguing with one another by promoting the idea that there are no wrong answers.

Data Analysis Overview What happens to the data you collect? Qualitative Data Analysis- Looking for: Patterns or common themes Deviations from the pattern Interesting stories Missing data we can collect in the future Does the data support or contradict other data you have collected? Qualitative analysis can be completed in a number of different ways, but generally this is how you are looking to interpret data. Unlike qualitative data, there is a lot of variation in how data is interpreted, and data is often looked at subjectively. More people reviewing data will minimize issues and help identify patterns, themes, and deviations. Qualitative data can be a powerful way to look more in depth at your Tribe’s health. You are the key to good qualitative data!

Thank you!!! For more information contact Sarah Price Public Health Associate National Indian Health Board 202-507-4078