What Influences Saturation? Estimating Sample Sizes in Focus Group Research.

Saturation is commonly used to determine sample sizes in qualitative research, yet there is little guidance on what influences saturation. We aimed to assess saturation and identify parameters to estimate sample sizes for focus group studies in advance of data collection. We used two approaches to assess saturation in data from 10 focus group discussions. Four focus groups were sufficient to identify a range of new issues (code saturation), but more groups were needed to fully understand these issues (meaning saturation). Group stratification influenced meaning saturation, whereby one focus group per stratum was needed to identify issues; two groups per stratum provided a more comprehensive understanding of issues, but more groups per stratum provided little additional benefit. We identify six parameters influencing saturation in focus group data: study purpose, type of codes, group stratification, number of groups per stratum, and type and degree of saturation.

"I have no choice": Influences on Contraceptive Use and Abortion among Women in the Democratic Republic of the Congo.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

Retention in HIV care depends on patients' perceptions of the clinic experience.

Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.

Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough?

Saturation is a core guiding principle to determine sample sizes in qualitative research, yet little methodological research exists on parameters that influence saturation. Our study compared two approaches to assessing saturation: code saturation and meaning saturation. We examined sample sizes needed to reach saturation in each approach, what saturation meant, and how to assess saturation. Examining 25 in-depth interviews, we found that code saturation was reached at nine interviews, whereby the range of thematic issues was identified. However, 16 to 24 interviews were needed to reach meaning saturation where we developed a richly textured understanding of issues. Thus, code saturation may indicate when researchers have "heard it all," but meaning saturation is needed to "understand it all." We used our results to develop parameters that influence saturation, which may be used to estimate sample sizes for qualitative research proposals or to document in publications the grounds on which saturation was achieved.

Pathways That Affect Wives' HIV Risk Among Serodiscordant Couples in India: Results From the Positive Jeevan Saathi Study.

This study examined factors that mitigate or heighten HIV risk among HIV-negative wives in serodiscordant relationships in Gujarat, India. Grounded theory was used to analyze 46 interviews (23 couples) where husbands were HIV-positive and wives were HIV-negative. A conceptual framework emerged from analysis from which we identified five pathways and four key behaviors: (a) safer sex, (b) no sex, (c) coercive sex, and (d) unprotected sex. Most couples either practiced safe sex or abstained from sex. Factors such as wives' assertiveness, a wife's fear of acquiring HIV, mutual understanding, positive sex communication, and a husband's desire to protect wife influenced safe sex/sexual abstinence. Factors such as desire for children, a husband's alcohol use, and intimate partner violence influenced coercive and unprotected sex. Counseling topics on sex communication, verbal and non-verbal safer sex strategies, as well as addressing intimate partner violence and alcohol use may be important in preventing risk to HIV-negative wives.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial.

BACKGROUND: Structured lifestyle change education reduces the burden of cardiometabolic diseases such as diabetes. Delivery of these programs at worksites could overcome barriers to program adoption and improve program sustainability and reach; however, tailoring to the worksite setting is essential. METHODS: The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at 11 large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, and peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. RESULTS: Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add a wider variety of exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. CONCLUSION: This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. TRIAL REGISTRATION: Clinicaltrials.gov NCT02813668. Registered June 27, 2016.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial.

Background: Delivery of proven structured lifestyle change education for reducing the burden of cardiometabolic diseases such as diabetes at worksites could overcome barriers to program adoption and improve sustainability and reach of these programs; however, tailoring to the worksite setting is essential. Methods: The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at eleven large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. Results: Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. Conclusion: This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. Trial Registration: Clinicaltrial.gov NCT02813668, registered June 27, 2016.

A qualitative study of sexual behavior change and risk compensation following adult male circumcision in urban Swaziland.

Male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomized controlled trials. Less is known, however, about sexual behavior change in men who have been circumcised and whether male circumcision's protective effect leads to riskier sexual behaviors. This study used qualitative in-depth interviews to understand men's sexual behavior after circumcision and to determine whether and how men participated in riskier sexual behaviors following male circumcision. Men in urban Swaziland, circumcised in the previous 12 months, were recruited and asked about their perceptions of sexual risk and sexual behavior post-circumcision. Results showed that following circumcision, men experience changes in both their sexual attitudes and behavior, which can be considered both protective and risky for HIV transmission. Most of them described protective changes (e.g., more responsible attitudes towards safe sex, reducing sexual temptation and partners, easier condom use). A minority, however, experienced increased sexual risk-taking, typically during a brief period of sexual experimentation shortly after circumcision. HIV counseling and counseling throughout the circumcision process is shown to be critical in influencing protective behaviors. Findings in this study confirm the existence of risk compensation following circumcision; however, this study adds important contextual insight about precisely when and why such risk-taking occurs. Nevertheless this study suggests that male circumcision scale-up as an HIV prevention strategy is likely to foster protective behavior change among men. The integration of HIV counseling with circumcision provision remains critical for effectively mitigating HIV risk behavior as male circumcision gains momentum as a viable HIV prevention tool.

Tailoring lifestyle programmes for diabetes prevention for US South Asians.

Objective: The purpose of this study was to develop and test the feasibility of a culturally tailored Diabetes Prevention Programme (DPP) for US South Asians, a large population with high diabetes risk. Design: The South Asian Health and Prevention Education (SHAPE) study included: (1) focus group discussions with South Asian adults to understand views of lifestyle behaviours and diabetes prevention; (2) modification of the US DPP for South Asians and (3) a pilot, pre-post study to test the feasibility and impact of delivering the culturally tailored programme. Setting: The study was conducted in Atlanta, Georgia, USA. Focus group discussions and intervention classes were held at locations within the community (eg, South Asian restaurants, a public library, university classrooms, a South Asian owned physical therapy studio). Participants: The focus group discussions (n=17 with 109 individuals) included adults aged 25 years of older who self-identified as South Asian. Groups were stratified by age (25-40 years or older than 40 years) and sex. The SHAPE pilot study included 17 (76.5% male with a mean age of 46.9±12 years) South Asian adults aged 25 years or older with pre-diabetes and body mass index (BMI) >22 kg/m2. Results: Formative data from 17 focus group discussions and a community board guided the modification of the DPP curriculum to reflect cultural food preferences and include tools to leverage social support, create a stronger foundation in exercise and overcome culturally specific barriers. The SHAPE pilot study included 17 South Asian adults with pre-diabetes and BMI >22 kg/m2. There were positive changes in participants' weight, waist circumference, blood pressure, plasma lipids, HbA1c and other cardiometabolic markers postintervention and 55% of participants regressed to normoglycaemia. Conclusion: These results provide important information on the barriers faced by US South Asians in participating in 'standard' lifestyle change programs, indicate the feasibility of culturally tailored programmes and show positive impact of a culturally tailored programme for diabetes prevention in the South Asian population.

Norms of Masculinity and the Cultural Narrative of Intimate Partner Violence Among Men in Vietnam.

Semi-structured interviews with 31 men in Hung Yen Province in Northern Vietnam are used to elucidate a conceptual narrative to understand men's perceptions and perpetration of intimate partner violence (IPV) in Vietnam. This narrative suggests that cultural definitions of masculinity and changes in women's participation in the labor force have contributed to status conflicts that normalize IPV as part of masculine superiority. The narratives of both IPV perpetrators and non-perpetrators demonstrate how violence is incorporated into the cultural definition of masculinity and illustrates how men use this definition to minimize their own and other men's perpetration. We suggest that attempts to reduce IPV in Vietnam must address constructions of masculinity and the socio-historical context of IPV by providing gender-sensitivity training and opportunities for men to evaluate critically how constructions of masculinity in their families and communities contribute to IPV perpetration.

Pathways to Retention in HIV Care Among U.S. Veterans.

Retaining HIV patients in clinical care is a critical component of the HIV care continuum, impacting not only patients' virologic suppression, but their overall health and wellbeing. Understanding reasons for patient drop-out is therefore important to improve HIV outcomes and reduce transmission. This study used qualitative in-depth interviews with patients who dropped out of HIV care (n = 16) from the Atlanta Veterans Affairs Medical Center, to explore their reasons for drop-out and how they negotiate barriers to return to care. Results show three interlinked "pathways" leading to patient drop-out -wellness, illness, and medication pathways. These pathways encompass both barriers to retention and triggers to resume clinic visits, with patients following different pathways at different times in their lives. Perhaps the strongest deterrent to continuing clinic visits was participants' self-perception of wellness, which often outweighed clinical indicators of wellness. These pathways suggest that multiple approaches are needed to improve treatment retention, including reducing clinic-based barriers, addressing basic needs that are barriers to clinic visits, and empowering patients to view clinic visits as a facilitator to maintaining their overall health rather than only a reaction to illness.

How are qualitative methods used in diabetes research? A 30-year systematic review.

We aimed to describe how qualitative methods are used in global research on diabetes and identify opportunities whereby qualitative methods could further benefit our understanding of the human experience of diabetes and interventions to address it. We conducted a systematic review of National Library of Medicine, EMBASE, and Web of Science electronic databases to identify original research articles that used qualitative methods to study diabetes between 1980 and 2011. We identified 554 eligible articles and categorised these by geographic region, year of publication, study population, study design, research question, qualitative data collection methods, and journal type. Results show low use of qualitative methods in diabetes research over the past 30 years. The majority of articles (75%) reported using substantive qualitative research, while mixed-methods research has remained underutilised. Eighty-five per cent of articles reported studies conducted in North America or Europe, with few studies in developing countries. Most articles reported recruiting clinic-based populations (58%). Over half (54%) of research questions focused on patient experience and 24% on diabetes management. Qualitative methods can provide important insights about socio-cultural aspects of disease to improve disease management. However, they remain underutilised for understanding the diabetes experience, especially in Africa and Asia and amongst non-clinic populations.

Exploitation, vulnerability to tuberculosis and access to treatment among Uzbek labor migrants in Kazakhstan.

In recent years, Kazakhstan has become an important destination for primarily undocumented seasonal workers from Uzbekistan. In a context of high tuberculosis (TB) incidence, TB treatment is provided free for all residents in Kazakhstan, but migrants rarely access these services. This paper reports findings from a qualitative study conducted with migrants, TB patients and health care workers between July and September 2008 to understand the mechanisms that impede migrants' access to care. Findings describe three structural contexts--the employment, legal and health care contexts - which act in concert to render migrants vulnerable to exploitative work conditions and cause a series of barriers to health care. These conditions contribute to increased exposure to TB, heightened risk of reactivation due to weakened immunity, treatment-seeking delays, and increased severity of disease. Seasonal migration patterns also contribute to treatment interruption, which constitutes a risk for the creation of drug resistance. Using the theory of structural violence coupled with the concept of cumulative vulnerability, this paper analyzes how illegality interacts with exploitation and social marginalization to produce vulnerability to TB and restrict access to treatment.

Barriers to Testing and Treatment for Chagas Disease among Latino Immigrants in Georgia.

Background. The lack of testing and treatment of Chagas disease (CD), caused by Trypanosoma cruzi, amongst infected immigrants in the USA increases the risk of serious health complications and transmission (congenital or via blood transfusions). Goal. Our goal was to identify the barriers to testing and treatment of CD and understand the process of seeking healthcare amongst Latino immigrants in Georgia. Methods. In this qualitative study, eleven focus group discussions were conducted with 82 Latino immigrants, including migrant farm workers. Grounded theory was used to collect and analyze the data to develop an inductive conceptual framework to explain the context and process of seeking healthcare for CD amongst this at-risk population. Results. Participants were not aware of CD. Three healthcare seeking behaviors were identified: delaying treatment, using traditional remedies, and using either mainstream or alternative health providers. Behaviors and motivations differed by gender, and the use of licensed medical providers was considered a last resort due to the cost of healthcare, loss of earnings while seeking care, and fear of diagnosis with fatal illness. Discussion. Providing free or low cost services, mobile clinics, and education regarding CD is critical to increase testing and treatment of CD in the US.

Perceptions of sex education for young people in Lesotho.

This study aimed to identify the views of young people, parents and teachers concerning sex education in Lesotho. It was conducted at a time when the national government was considering the introduction of Population and Family Life Education, which includes sex education, into the national school curriculum. Forty-six focus group discussions were held with young people (10), parents (30) and teachers (6) to identify current sources of sex education and views of the proposed introduction of school-based sex education in Lesotho. Findings show the limited and problematic sources of sex education for adolescents in Lesotho. They also highlight broad support for the introduction of sex education in the national school curriculum among young people, parents and teachers. Of key importance for the development of a sex education curriculum is the balance between providing young people with information and developing their skills in sexual empowerment and negotiating sexual pressure. The use of pupil-centred interactive pedagogies was seen as essential. Teachers, however, highlighted the need for training in the delivery of sex education, which includes instruction on course materials, teaching methodologies and developing sensitivity to teaching sexual issues to young people.