A UNIQUE “STORY COMPLETION” RESEARCH METHOD FOR OBTAINING ACCURATE SURVEY DATA
Linda LL Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA: Independent Researcher/Educator for Village Health Workers and Ferris Mfg. Corp. LindaBenskin@utexas.edu
The Benskin village health care research is funded by individual donations, supplemented by occasional small grants or scholarships. Dr. Benskin retains full independence in the conduct of this research.
Background
Unrelenting heat, poor sanitation, lack of knowledge, and poverty contribute
to a disabling wound prevalence that often exceeds 20% in rural areas of
tropical developing countries.1 In developed countries, the most common
cause of a chronic wound is a chronic illness, but in developing countries,
most chronic wounds are the result of an ineffectively managed acute
wound.1 Traditional health practitioners and village health workers, rather
than licensed health professionals, provide health care beyond self-care in
most villages.1
Wound management education for these nonprofessional health providers
should include only sustainable practices which are safe and effective in
the tropical village setting (they must be ecologically valid) 1 An extensive
literature search revealed no published descriptions of current usual wound
management practices in this setting.2
Aims
A culturally-appropriate quantitative study design was needed to obtain
accurate detailed descriptions of usual wound management practice in
rural areas of tropical developing countries.1 Barriers to obtaining accurate
survey data in rural areas of tropical developing countries are formidable,
and include:1
1. Cultural differences that prevent classical pencil and paper surveys from
being understood
2. A universal reluctance to expose ones’ work to strangers for evaluation
3. A strong sense of hospitality which dictates that participants provide
answers they believe the investigator will find pleasing, even if these are
not at all accurate answers
4. The possibility of the survey focusing upon problems (in this case,
wound scenarios) that are not relevant to the participants
Method
After the interpreter read the study explanation and consent was obtained,
the semi-structured interview was guided by wound patient case studies
(see box, right, for details). Full-page laminated photos of seven wounds at
initial presentation were shown to each participant, one wound at a time.
The “story” of how the wound developed prior to presentation (patient
history) was read to the participant by the researcher. If the participant
stated that they were familiar with this type of wound AND would manage it,
the researcher asked, “What would you do?” (to complete the “story”).
After the participant completed each patient’s story, the researcher
repeated each intervention back to the participant in chronological order,
asking if this was correct, and if they would do anything before or after this.
If the participant added anything, the researcher repeated the interventions
they described back again. This iterative process was followed until the
participant stated that the story was complete. Then, the story for the next
wound was described in the same way. No prompts were provided to the
participants. It was assumed that anything omitted was not done.
Barrier 1 was addressed by placing case studies within a story completion
framework to elicit wound care details from the study participants.1 Oral
story-telling is integral to most cultures in developing countries, and has
been used successfully to enhance communications about health issues in
these settings.3 Photographs were used to further enhance communication.
Using disassociated case studies and emphasizing the anonymous nature
of the data in the study design helped to address barrier 2.1 Disassociated
case studies are less psychologically threatening than discussing ones’
own behavior.4
The participants were first asked if the example patient’s wound was of a
familiar type and if they would actually manage this wound type. 1 Providing
this opt-out helped keep wild speculation due to barrier 3 from entering the
data.1 Barrier 3 was further addressed by asking only a few carefully
worded questions to elicit a detailed description of how the participant
would usually manage each of seven wound types.1 Asking only open-
ended questions avoided inferring to the participant that any particular
aspect of wound management, such as cleansing or debridement, was
expected.1 This also decreased the likelihood of interviewer bias creeping
into the data.5 Open-ended survey questions have been used successfully
by other researchers in Africa to diminish problems with inferring answers
to participants and to diminish surveyor bias.5
Selecting the Case Studies to Guide the Interviews:
a Qualitative Pre-Study to Address Barrier 4
Thirty actual wound cases (photos and brief patient histories)
taken from the investigator’s portfolio of wounds managed in a
remote clinic in northern Ghana were presented to five Ghanaians
who are experienced in wound care and familiar with village life. 1
These experts each provided free responses to twenty questions
about the wound cases in a qualitative pre-study to ensure that the
questions were relevant (barrier 4).1
The researcher anticipated that this pre-study would narrow the
wound cases down to one representative patient for each of the
five common wound types she had identified previously. The
Ghanaian experts surprised the researcher by predicting
(accurately) that osteomyelitis is also common in villages,1
presumably because often bones are not set properly, resulting in
malunions. And, they insisted that cancerous ulcers are
encountered in villages.1 This may be because cancer tends to
develop at chronic wound sites (squamous cell carcinoma) and in
scars (Marjolin’s ulcer carcinoma).6 Thus, the pre-study participants
identified seven representative wound types, each with its own
exemplar case study, for the survey to obtain detailed data on
wound practices.1
The Seven Wound Cases Presented to the Survey
Participants1
Abscess: “A young man has come to
you with a painful, very swollen hand.
The problem began a few days ago,
but it is getting worse. He has not
treated it in any way. He can no longer farm because of the pain
and swelling. The young man does not remember anything that
may have caused the problem – he says, 'It came on its own.'”
Burn: “A small child walked into a burn pit that still had hot items in
it under the ashes and burned his feet a
few days ago. The child refuses to walk
and cries all the time, so the mother is
bringing the child to you for help. The
larger blisters have been burst, but there are a few small intact
blisters on the toes of the right foot.”
Schoolchild with leg ulcers: “A school
child developed a leg ulcer that is so painful
that it is becoming difficult to walk. The
wound is producing small amounts of thick
yellow foul-smelling drainage. The child does not remember how
long ago the ulcer came.”
Chronic ulcers: “This wound has been a problem for the patient
for more than a year.
The patient has tried
many remedies, but
none led to long-term
improvement. A relative recommended that he come to you for
healing. The wound is very painful.”
Trauma: “A farmer was working his
field when he stepped on a sharp stick.
The stick went completely through his
foot and caused a lot of bleeding. He
wrapped his foot in a cloth and
immediately bicycled to you for help.”
Osteomyelitis: “The skin over a broken bone has
healed, but a small wound with thick foul-smelling
yellow drainage keeps appearing at the site of the
scar.”
Cancer: “The patient has a non-healing wound
that is only a little painful. There is a large amount
of over-growth of tissue at the site, and more
comes every day. The scent is very terrible.”
Testing the Story Completion Method in Ghana
From August through October of 2012, the investigator
interviewed a village health worker, a traditional health
practitioner, and an untrained villager who performs
wound self-care in each of 25 diverse villages
throughout Ghana to elicit detailed descriptions of
current usual topical wound management methods.1
The 75 participants were asked to complete the stories
of seven wound patients (see box, left), each
representing one of the common wound problems
found in this setting, without prompts.1 Carefully
worded open-ended questions avoided inferring that
any particular aspect of wound management, such as
cleansing, is expected.1 The study was approved by
UTMB's ethics IRB.1
Interviews were audio recorded with redundant
password protected devices.1 Discrete responses for
each aspect of wound management for each wound
type were coded onto a spreadsheet as if they had
been obtained with a conventional survey. Responses
were tabulated and categorized as congruent or not
congruent with modern topical wound management
principles within three domains and six subcategories
(see table, below, right).1 Responses were analyzed
using standard quantitative statistics with SPSS to
answer four research questions.1
Results
The study participants offered detailed descriptive
responses, verifying that the story completion method
was comfortable to them (barrier 1). Most indicated
that the seven chosen wound exemplars were familiar
to them (barrier 4).1 As was predicted by several of the
Ghanaian experts, the participants in the study often
indicated that they felt honored to be invited to share
their knowledge, affirming that the study design was a
sound one for overcoming barrier 2.1 The eclectic and
detailed nature of the participants’ responses indicates
that they did not simply provide answers they believed
would be pleasing to the researcher (barrier 3).1
However, coding the data was an arduous process,
made far more difficult by background noise. Digitally
isolating voices from other sounds would be helpful.
Subsequently, the method was employed for traditional
health providers and villagers performing self care in
remote villages of Cambodia, using the same seven
wound types. The story completion method again met
the study goals of obtaining accurate detailed
descriptive responses, despite the dramatic difference
in culture. However, although tropical ulcers were
problematic in Cambodian farm communities, they are
a rare wound type in floating villages. The researcher
tested the water in the Tonle Sap Lake, where these
villagers bathe, and found it to be acidic.
Conclusion
Using representative actual examples as story prompts
to elicit objective data via the free response story
completion method, with no prompts, overcame all four
identified barriers that have prevented researchers
from discovering usual wound management practices
in villages in the past. The cases chosen to be used as
prompts must be individualized to the setting.
Implications
This study design can be implemented in other settings
with other research topics. Such experimentation will
determine how broadly it can be used to overcome
common barriers to obtaining accurate survey data.
A Snapshot of the Pilot Study
More than 50% of the time, the study participants' goals were
compatible with modern wound management principles.1 While
safe wound cleansing and debridement were not described
consistently, most of the providers described moist wound
treatments, regardless of the wound type.1 Most participants cover
wounds with either a bandage of cloth strips or an occlusive herbal
poultice.1 Although they stated that their intent is to keep wounds
moist, except for in the most humid of settings, these coverings
clearly cannot always adequately accomplish this goal.
Participants from villages throughout Ghana were interviewed to
obtain detailed descriptions of their current usual topical wound
management methods using this new approach. This required
extensive travel to areas which are medically underserved due to
either remoteness or conflict. Village health workers, untrained
villagers who perform self-care, and traditional health practitioners
ranging from herbalists with Red Cross training to self-proclaimed
“witch doctors” were all eager participants in the study. Although a
private location was always requested by the researcher, often the
participant insisted upon responding before an admiring audience.
Ecosystem and village accessibility did not influence likelihood of
referral to a hospital.1 Compared with village health workers and
villagers performing self care, traditional health practitioners were
significantly less likely to refer the wound patients with the most
serious wounds to health professionals.1
This chief's
wound was
managed by the
local village
health worker.
The pilot study included least two participants from each of Ghana's diverse ecosystems,
which range from true tropical rain forests to the arid Sudanian savannas.
ORGANIZATION OF DATA (FOR EACH WOUND TYPE)
Congruent with modern wound principles?
Yes No
I. Wound Bed Preparation
A. Cleansing
B. Debridement
II. Wound Treatments
A. Infection/Moisture Control
B. Inflammation/Edema Control
III. Wound Dressings
A. Commercial Materials
B. Indigenous Materials
References
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a pilot study [dissertation]. [Galveston, TX]: University of Texas Medical Branch; 2013.
Available from: http://www.hdl/handle/10755/299522
2. Benskin LLL. A review of the literature informing affordable, available wound
management choices for rural areas of tropical developing countries. Ostomy Wound
Manage. 2013 Oct;59(10):20–41. PMID: 24106254
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Health (Abingdon). 2001;14(1):51–60.
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Patients Change Behavior. 1st edition. New York: The Guilford Press; 2007. 210 p.
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Health gains from solar water disinfection (SODIS): evaluation of a water quality
intervention in Yaoundé, Cameroon. J Water Health. 2010 Dec;8(4):779–96.
6. Asuquo M, Ugare G, Ebughe G, Jibril P. Marjolin’s ulcer: the importance of surgical
management of chronic cutaneous ulcers. Int J Dermatol. 2007 Oct;46 Suppl 2:29–32.