Using Vignettes In Qualitative Research To Explore Barriers And ...

Vignettes are short stories about a hypothetical person, presented to participants during qualitative research (e.g. within an interview or group discussion) or quantitative research, to glean information about their own set of beliefs. They are usually developed by drawing from previous research or examples of situations which reflect the local context, creating a story that participants can relate to. Participants are typically asked to comment on how they think the character in the story would feel or act in the given situation, or what they would do themselves. As the focus is on a third person, vignettes can be advantageous in research on sensitive topics where the participant may not feel comfortable discussing their personal situation and may conceal the truth about their own actions or beliefs. They can also, through normalisation of the situation, encourage participants to reveal personal experiences when they feel comfortable to do so [1–4].

Vignettes have traditionally been used in the developed world in (predominantly quantitative) research on psychology and potentially sensitive social and health issues such as sexual health, HIV, mental health, stigmatisation, violence, and in specific vulnerable populations such as children and drug users [1, 2, 4–13]. Hughes, and Barter and Renolds reflected critically on the methodology of vignettes with reference to their own research and other studies conducted in the developed world, concluding that the technique can be a valuable research tool despite debates surrounding their use: primarily the extent to which vignette responses mirror social reality [1, 4]. Studies from the developing world (including Africa) using vignettes have emerged more recently [14–24], but none have critically examined the use of vignettes in such settings. These studies have mainly focussed on similar topics to those investigated traditionally in North America and Europe, such as sexual health, mental health and stigma, but also include areas such as malaria and public health campaigns.

Very little qualitative research about HIV services in this setting, particularly prevention of mother-to-child transmission (PMTCT) of HIV or drug adherence (in the push for universal testing and treatment), has used vignettes to elicit perspectives of patients (or providers) regarding service or drug use. The few examples include Varga and Brookes’ study in South Africa, based on the narrative research method of the World Health Organisation [25]: vignettes were developed during workshops with ‘key informants’ and presented during focus groups and surveys with pregnant HIV-positive adolescents to investigate barriers to participation in PMTCT services [24]. Bentley et al. also used vignettes to investigate perceptions of HIV-positive mothers regarding breastfeeding practices and nutrition in Malawi [26]. Varga and Brookes discussed methodological implications of their approach, reflecting that adolescent mothers spoke more easily about their own experiences after discussing the story of another teenager, and suggesting that in-depth interviews (IDI) exploring personal experiences can be useful in verifying and understanding responses towards the vignette. However, neither paper evaluated the specific challenges nor advantages of applying vignettes in their setting, for example the extent to which respondents understood the directions they were given, or how well fieldworkers facilitated discussions or interviews containing vignettes.

Global commitments have been made to improve uptake of PMTCT services [27] in view of the low coverage noted in many African countries [28]. An emerging body of research is exploring reasons for low access and usage of PMTCT services: barriers include sensitive issues such as stigmatisation regarding HIV status, fear of disclosure to partners or other relatives, and psychological barriers including denial [29].

The potential for reporting bias in studies on barriers to PMTCT service use in sub-Saharan Africa has been noted [29], and in our study setting, under-reporting by women of other socially sensitive outcomes (e.g. number of sexual partners) was reported [30]. We therefore expected that a number of HIV-positive women would not admit to difficulties they faced when accessing PMTCT services, or would feel uncomfortable discussing such issues during interviews. Vignettes could consequently be a valuable and under-used tool in PMTCT/HIV research and drug adherence more widely. They may also offer a contribution to the range of methods available to reduce the social desirability biases encountered with self-reporting of outcomes in HIV, sexual and reproductive health research [31–33]. There is some discussion over whether responses to vignettes may also be socially desirable, particularly when respondents are asked how they themselves would act in the scenario presented. However, asking first how the fictional character would behave and why is thought to reduce the pressure to answer with socially desirable outcomes [4]. In this paper we describe the development and application of a vignette to an investigation of barriers and facilitating factors to uptake of PMTCT services in rural Tanzania. Our objectives for using the method were 1) to create a comfortable environment for IDIs and encourage women to openly discuss difficulties they or acquaintances faced in using PMTCT or maternal and child health services, and 2) to generate data on barriers and facilitating factors to uptake of PMTCT services from the perspective of HIV-positive and HIV-negative mothers, fathers and relatives. We critique the successes and challenges associated with employing vignettes in this setting, in order to determine the feasibility and utility of using this technique in qualitative investigations more widely in sub-Saharan Africa.