Abstract
This article examines the ways in which integrating a metatheory to guide qualitative interviews supports health theory and the research methodology of interviewing. This study applied Harm Reduction Theory (HRT) as a metatheory to the Reconceptualized Health Belief Model (RHBM) in targeting motorcyclists to practice safety behaviors. After integrating the metatheory with a health behavior theory to develop research questions and frame the interview guide, we recruited and interviewed 37 at-risk motorcyclists. The process of interviewing participants and the results of the study support the integration of harm reduction metatheory to enhance interview methodology as a way to effectively engage participants by building rapport, encouraging participants to apply theory, and empowering them to be open and honest in their responses. This research process highlights ways in which incorporating a metatheory to guide theory diverges from the more traditional, theory-driven approach to interviewing.
Keywords
This article discusses an enhanced approach to qualitative interviewing. This approach features a metatheoretical integration that emphasizes theory during health-related research and serves as guidance during interviews with participants. During an interview, researchers are continuously establishing rapport with participants, using theory as a conceptual guide, and empowering participants while staying true to the research questions. Throughout this article we discuss how incorporating metatheory into health-related research can help build rapport and communication with participants, foster an egalitarian relationship so participants can more easily discuss the barriers they encounter (Bateson, 1972; Benney & Hughes, 1970), ask questions in a non-threatening way (Lindlof & Taylor, 2002), and aid the development of an interview protocol.
Although this approach is not generalizable beyond the example provided in this study, we hope that by illustrating how we applied a metatheory to inform and guide our research methodology, metatheoretical integration will become more practical and researcher-friendly in future qualitative research. To instigate this addition to qualitative research, we discuss a study that applied Harm Reduction Theory (HRT) as a metatheory (Haas, 2012) to the Reconceptualized Health Belief Model (RHBM) (Mattson, 1999) in targeting motorcyclists to practice safety behaviors. We begin by presenting the integration of a metatheoretical perspective as a viable approach to strengthen interviewing methodology. We then showcase this metatheoretical perspective in a research project that highlights the infusion of harm reduction metatheory during interviews with at-risk motorcyclists.
Integrating a Metatheoretical Perspective
A theory assists in examining, organizing, and representing facts (Littlejohn & Foss, 2005) whereas a metatheory is an examination and analysis of theories (Weinstein & Weinstein, 1992). Hjorland (1998) offered a more specific perspective of conceptualizing a metatheory that fits well with our exploratory approach when he stated about metatheory: “Metatheoretic assumptions are thus broader and less specific than theories. They are more or less conscious or unconscious assumptions behind theoretical, empirical, and practical work. Metatheoretical assumptions are connected to philosophical views, and are often parts of interdisciplinary trends” (p. 607). Based on the scientific roots of Harm Reduction Theory (HRT), its broad tenets, and its interdisciplinary use in research and practice, using HRT as a metatheory might assist the researcher to engage the theory during the interview and allow participants to grasp abstract constructs from a theory while providing specific, in-depth stories related to their behaviors implied by those theoretical constructs.
The process of conceptualizing HRT as a metatheory was rigorous and followed a structured methodological process. Specifically, Edwards (2010) proposed eight phases in the design and assessment of a metatheory. A full description of this process and our adapted approach using the eight phases are provided elsewhere (Haas, 2012). After we progressed through these phases, an integrated model of metatheory and theory was developed. Before we discuss this integration, we summarize both Harm Reduction Theory and the Reconceptualized Health Belief Model.
Harm Reduction Theory
The primary goal of HRT is to “reduce the problematic effects of unhealthy behaviors” (Logan & Marlatt, 2010, p. 201), and it can include “techniques ranging from prevention to intervention to maintenance” (p. 203). The term harm reduction was not adopted until approximately the mid-1980s during the initial years of the HIV/AIDS epidemic (Stimson, 2007). Besides being used to combat the spread of HIV/AIDS by opening up needle-exchange facilities, harm reduction techniques are used to prevent negative consequences as a result of engaging in risky health and safety behaviors such as alcohol and other substance abuse and unsafe sexual activities (Logan & Marlatt, 2010). Other examples include passing laws requiring the use of seatbelts and helmets to reduce the chance of injuries as a result of risky driving. Harm reduction methods accept risky behaviors and, as a result, are discussed as a pragmatic prevention approach that supports any steps taken toward healthier behavior change (Marlatt, 1998).
HRT is comprised of five, broad tenets. Humanistic value acknowledges that people engage in risky health behaviors and expects that these individuals are treated in a nonjudgmental way (Marlatt, 1998); Pragmatism promotes being realistic about individuals' risky behaviors by focusing on harm-reducing actions instead of abstinence (Heather, 2006); Immediacy/Goal setting involves developing coping strategies, in the form of a hierarchy of goals, to begin reducing risky behaviors and consequences of those behaviors before looking toward a long-term goal (Mattson & Basnyat, 2008); Empowerment provides choices to individuals, allowing them to choose and implement short-term, pragmatic goals rather than long-term, idealistic goals (Reid, 2002); and Community collaboration consists of providing a setting that is not designated as a formal treatment area (Little & Franskoviak, 2010) to create “enabling environments” to facilitate behavior change (Rhodes, 2002).
Interventions informed by HRT have focused on individuals, small groups, organizations, communities, and policymakers. Broad use makes HRT well suited as a guide to practice in virtually every setting (Bigler, 2005). Despite researchers, practitioners, and lay people noting the usefulness of HRT, it has encountered several barriers due to its controversial, inconsistent, and perhaps impractical use as a theory. We argue that the conceptual tenets of HRT are broad enough to guide the ways theoretical frameworks are utilized when communicating with participants, which makes HRT more appropriate as a metatheory. Coupled with practical health-oriented theories, HRT at the metatheoretical level also may advance qualitative research and practice.
Reconceptualized Health Belief Model
The Reconceptualized Health Belief Model (RHBM) (Mattson, 1999) originated from the Health Belief Model (HBM). The HBM was developed in the 1950s to understand the consistent failure of people to participate in preventive health behaviors, such as screening tests or vaccinations (Rosenstock, 1974). The HBM consists of several components. First, perceived benefits are “an individual's beliefs regarding the effectiveness of strategies designed to decrease vulnerability or reduce the threat of illness” (Brown, DiClemente, & Reynolds, 1991, p. 51). Perceived barriers are “the assessment of potential negative consequences that may result from taking particular health actions” (Brown et al., 1991, p. 51). Individuals are more likely to adopt a preventive behavior if the benefits of doing so exceed the barriers. Brown et al. (1991) defined perceived severity as an individual's perception of the seriousness of the health threat and perceived susceptibility as an individual's perception of risk relative to that health threat. Another aspect of the RHBM is self-efficacy, which is an individual's perception that the behavior necessary to reduce harm can be practiced effectively (Bandura, 1977). Finally, the RHBM emphasizes communication cues to action as stimuli central to initiating behavior change, which recognizes that individuals who engage in risky behaviors often need a communication cue to stimulate decision-making behaviors (Mattson, 1999).
One aspect of developing a metatheory includes analyzing a variety of theories for complementarity with the paradigm and metatheory (Ritzer, 2001). Several theories were analyzed before concluding that the RHBM was best suited to initially be guided by the proposed metatheory (Haas, 2012). This conclusion was drawn because the RHBM assumes that individuals are rational decision makers and can make their own choices (Wundersitz, Hutchinson, & Woolley, 2010). Similarly, HRT assumes that individuals can and should make their own choices (Reid, 2002).
Harm Reduction Theory as a Metatheory to Guide Theory and Interview Methodology
The subsequent section describes a study that utilized harm reduction as a metatheoretical framework. After discussing the general design of the study, each sub-section highlights a tenet of HRT and integrates it with a component of the RHBM.
Study Design
The Institutional Review Board (IRB) at a Midwestern University deemed this project IRB exempt. Participants were recruited through posted flyers, online flyers, network sampling, and snowball sampling. We recruited and interviewed self-identified risky motorcyclists (i.e., did not wear a helmet and/or safety gear, regularly sped and/or consumed alcohol before riding, and/or was in a motorcycle accident or nearly missed having a motorcycle accident) to assess the proposed metatheoretical framework. Thirty-seven motorcyclists participated in a face-to-face, semi-structured interview during which open-ended, predetermined questions guided the conversation (Lofland, Snow, Anderson, & Lofland, 2006). Semi-structured interviews allowed us to ensure that the questions were addressing the research questions of the study (Patton, 2002).
Of the 37 motorcyclists who participated, twenty-nine (n=29) were male and eight (n=8) were female. The participants ranged in age from 18 to 70, with a mean age of 40.5 years. The average number of years participants had been riding a motorcycle was 17.5, with a range of six months to 54 years. Participants from the sample were residents of 13 different cities within nine counties throughout one Midwestern State. All participants identified themselves as an at-risk motorcyclist based on the qualifiers provided by the researcher.
HRT Tenets Informing RHBM Components
In the following sub-sections a tenet of HRT is discussed, including the proposed integration of the tenet with a component of the RHBM. Interviews about motorcycle safety illustrate the integrated framework and its impact on interviewing methodology. The connections between a tenet of harm reduction and a component of the RHBM are also presented in Table 1.
Proposed Guidance from Harm Reduction Tenets to Application of Reconceptualized Health Belief Model Components
HRT Humanistic Value Informing RHBM Cues to Action
When applying the tenet humanistic value it is important to recognize that a problem exists and treat the individual who is engaging in the risky health behavior with respect (Brocato & Wagner, 2003; Riley & O'Hare, 2000). To be consistent with humanistic values when initiating cues to action, it is important to maintain nonjudgmental communication so that at-risk individuals begin to appraise their risk of a negative health outcome rather than react to how you are communicating with them about the at-risk behavior.
Regarding motorcycle safety, practicing humanistic value encourages individuals to respect the choices motorcyclists make and strive to raise awareness about their safety behaviors. Cues to action that motorcyclists may respond to include keeping a helmet with the keys to the motorcycle, viewing a persuasive message, or having a conversation with someone about motorcycle safety. However, a news story about a local motorcycle accident, or a safety campaign, also can serve as a cue to action (Haas, Mattson, Jones, & Morris, 2013). At times, motorcyclists might just need to be reminded to wear a helmet when riding a motorcycle.
Humanistic value and cues to action are central to the proposed metatheory/theory integration. For example, it is possible that upon receiving a nonjudgmental cue to action, an individual may begin assessing personal susceptibility to a crash whereas another individual may begin thinking of how to build safety skills, such as taking a motorcycle safety course. Therefore, it is imperative to begin an interview by engaging a humanistic value to gain participants' trust and attention, understanding that based on their current situation, they may gravitate toward different behavioral changes.
HRT Pragmatism Informing RHBM Perceived Benefits/Barriers
Within HRT, pragmatism is the notion of being realistic about individuals' behaviors and focusing on initial harm-reducing behaviors that are associated with their risks (Reid, 2002). In the RHBM, perceived benefits are beliefs regarding decreasing vulnerability as a result of changing behaviors and perceived barriers are the appraisal of negative consequences that might result from health behaviors (Brown et al., 1991). When individuals evaluate the pros and cons of replacing risky behaviors with healthier choices, being practical is necessary to overcome personal barriers.
Regarding motorcycle safety, uncovering barriers that motorcyclists perceive to being safer is necessary to know what messages are needed to address those barriers. For example, perceived barriers can be as simple as difficulty finding a comfortable helmet. In general, individuals often perceive more benefits from engaging in riskier driving behaviors than safer driving behaviors (e.g., speeding to feel a thrill) (Zuckerman, 1994). Utilizing pragmatism to inform a conversation with at-risk motorcyclists should help motorcyclists identify more benefits to driving within the speed limit, among other safer behaviors.
HRT Immediacy/Goal Setting Informing RHBM Perceived Susceptibility/Severity
Another tenet of HRT focuses on setting immediate and short-term goals based on the extent of risky health behaviors and how those behaviors influence the individual and their community (Mattson & Basnyat, 2008). The RHBM predicts that if cues to action are strong enough and individuals assess their perceived risk as high, they are more likely to act in compliance with the recommended health behavior (Mattson, 1999). Integrating immediacy/goal setting during communication with at-risk individuals might positively influence perceived susceptibility by supporting the development of steady, realistic goals toward healthier behaviors.
Perceived susceptibility is considered a determinant of risky driving behaviors, but it is difficult to engage motorcyclists' thinking about susceptibility because they often consider themselves invulnerable to injury and/or death (Chua & Job, 1999). However, dialogue with motorcyclists about what is in their immediate control to lower their susceptibility to an accident can occur following major motorcycle crashes, which often is a period during which they perceive higher susceptibility and might reduce their immediate risk for injury.
HRT Empowerment Informing RHBM Self-Efficacy
Encouraging empowerment by offering choices, developing response scripts for when temptation occurs, and pinpointing what interferes with practicing healthier behaviors can serve as ways to increase self-efficacy. Self-efficacy is an individual's perception that he or she can successfully practice an intended behavior necessary to reduce harm (Bandura, 1977). When self-efficacy is low, and when risk perceptions increase, personal intentions might unconsciously decrease because individuals perceive they have no other alternatives (Rogers & Mewborn, 1976). Empowering dialogue helps these individuals assess strengths and weaknesses, and in essence, make sense of their behaviors and beliefs while considering the possibility of change (Miller & Rollnick, 1991).
Utilizing the notion of empowerment during conversations with motorcyclists includes providing them with choices toward safer driving behaviors. For example, if motorcyclists cannot afford to buy a full set of safe riding gear, there could be one essential item they can afford immediately (e.g., helmet).
HRT Community Collaboration Informing Formative Research and Audience Analysis
Community collaboration to create enabling environments conducive to reducing individual harm is crucial, whether through public policy or removing structural barriers impeding behavior change (Rhodes & Hedrich, 2010). With regard to motorcycle safety, community collaboration can facilitate all aspects of the RHBM and promote a better understanding of the target audience of motorcyclists. For example, collaborating with media organizations can initiate more targeted cues to action among motorcyclists (Haas et al., 2013). Perceived barriers to safety might be reduced by making the environment more user-friendly, such as by fixing potholes in roads and providing ample parking for motorcycles. These efforts require collaboration with community organizations and policymakers. In addition to considering partnerships, it is important to continually assess the demographic and sociopsychological aspects of target audience members.
Next, we enact the proposed integration of metatheory and theory by discussing how integrating HRT with the RHBM assisted us in framing research questions, developing an interview guide, and conducting interviews. Then, we provide the results for each research question and present a summary of our theoretically-integrated process.
HRT Informing RHBM Research Questions about Motorcycle Safety
The research questions were framed to probe and understand how the tenets of harm reduction as a metatheory might guide the RHBM and the research methodology in promoting health behavior change.
RQ: In what ways can Harm Reduction Theory (HRT), in tandem with the Reconceptualized Health Belief Model (RHBM), guide interviews with motorcyclists about their safety behaviors while driving a motorcycle?
RQ1: humanistic value informing cues to action.
RQ2: pragmatism informing perceived benefits and perceived barriers.
RQ3: immediacy/goal setting informing perceived susceptibility and severity.
RQ4: empowerment informing self-efficacy.
RQ5: community collaboration informing formative research and audience analysis.
Harm Reduction Metatheory Informing the Interview Process
This section features how a metatheory can inform the development of an interview guide. Typically, an interview guide that is structured by a theory inquires about behaviors implied by the theory (highlighted in Table 2, column 3) (Rubin & Rubin, 2012). Our interview guide was structured differently in that the metatheoretical tenets of harm reduction were utilized to engage the components of the RHBM throughout the interview questions (highlighted in Table 2, column 2). Specifically, we adapted questions to include a harm reduction perspective while eliciting participants' attitudes and opinions relative to the components of the RHBM.
Implementing a Metatheoretical Framework to Guide Interviews
The interview guide included an introduction, five individual sections to assess each HRT tenet with the RHBM, and a conclusion. In addition to the general introduction, there was a brief opening to each of the five sections of the interview, which corresponded to the tenets of HRT. These openings included harm reduction terminology in an effort to build participants' trust, increase their comfort in responding to questions, and encourage reflexivity during the interview (highlighted in Table 2, column 1).
Before each interview section we inserted a “mental note for the researcher” relating to the HRT tenet being utilized in that respective section. The mental note for the humanistic value section was, “Ensure that the participant knows that, even though he/she may engage in risky behaviors while riding a motorcycle, I still respect the individual.” This mental note reminded us to be nonjudgmental toward participants and their behaviors and helped ensure participants' comfort in communicating at-risk and sometimes illegal behaviors while driving a motorcycle. When using humanistic value as a metatheoretical tenet in other research, this mental note can apply as a reminder for any health issue. For example, if interviewing underage college students about their alcohol consumption behaviors, it would be important to maintain a nonjudgmental attitude toward their alcohol consumption behaviors, despite potential participants being under 21 years of age.
With this mindset, we introduced the humanistic value/cues to action section of the interview guide by stating, “I know that motorcyclists, including you, may regularly engage in risky behaviors while riding. I recognize that these behaviors exist and am not here to judge you, rather I'd like to learn from your responses.” This opening immediately communicated that although we expect participants to practice risky behaviors on the road we do not judge those behaviors; rather, we want to understand those behaviors.
As we continued to conduct interviews with motorcyclists and engage in initial coding, we started to notice that integrating harm reduction terminology at the beginning of each interview section helped engage participants in the metatheory. This engagement was facilitated by each section introduction. These introductions, guided by metatheory, created a less abstract and more action-oriented discussion of theoretical components and encouraged participants to openly share their experiences. An example of a section introduction is as follows:
Now that we have talked about your general view toward motorcycle safety, and the benefits and barriers of practicing safer behaviors, I would like to discuss how you view your susceptibility to motorcycle accidents and injuries. During this section I would like to explore what situations have caused or may cause any short-term or long-term changes to your safety behaviors, recognizing that you may or may not have a desire to change behaviors at this point in time.
After introducing each section of the interview, we proceeded to ask the questions for that particular section. The main questions in each of the five sections were open-ended, and we included additional probing questions to fully understand participants' responses (Berg, 2004). Besides using HRT to structure interview questions, we consulted literature including Mattson's (1999) RHBM scales to survey HIV-test clients and Ross, Ross, Rahman, and Cataldo's (2010) HBM scales to predict safety behaviors among bicyclists. We adapted these questions from survey items to open-ended questions to assess motorcyclists' desire and ability to adjust at-risk behaviors.
For example, Ross et al. (2010) identified family and friends as a strong cue to action for bicyclists to practice safer behaviors when they bicycle. Therefore, one question in the interview protocol was, “How do your family and friends respond to your motorcycle safety behaviors?” This was followed by the probing question, “How do their responses make you feel?” Asking participants to explain their family and friends' views and how their family and friends communicate their viewpoints (e.g., positive, emotional, judgmental) allowed us to gauge if this particular cue to action can encourage motorcyclists to change behavior and, from a harm reduction standpoint, if the way family and friends communicate influences how motorcyclists respond to safety advice and concerns. We followed a similar approach to develop questions to assess media as a possible cue to action for participants. Participants discussed if the way media communicates about motorcycle safety is positive or negative and if the format of media messages influences their behavior.
Another example involves the design of interview questions to address perceived susceptibility and severity, guided by the immediacy/goal setting tenet of HRT. Ross et al. (2010) quantitatively identified the impact of short and long trips on bicyclists' safety behaviors. However, besides just assessing the impact of trips on safety behaviors, the interview questions also incorporated the HRT tenet immediacy in probing whether or not participants recognized and were open to developing short-term safety goals. To illustrate, one section of the interview guide designed to address perceived susceptibility/severity included these questions: “How often do you go on long trips? Short trips?”; “In what ways, if any, does the length of your trip determine what safety behaviors you practice?”; “Explain why you think it is easier or harder to practice safer behaviors on particular trips”; and “How does this affect your safety behaviors both close to home and further from home?” These questions encouraged participants to discuss their safety behaviors on short and long trips and the difference in these behaviors, while providing space to discuss short-term goals to reduce harm when driving a motorcycle.
As this section confirmed, preliminary research is important to understand the health and safety issue enough to probe participants. However, the way in which questions were developed, using the overarching tenets of harm reduction to educe the components of the theory, is a new approach to framing questions. The next section discusses ways in which the tenets of HRT engaged participants during the interviews.
Harm Reduction Metatheory Engaging Participants during Interviews
Using the tenets of HRT as a metatheoretical framework in this research project revealed that each tenet could guide a theoretical component and uncover barriers to behavior change. First, utilizing the concept of each tenet to initiate different safety topics with participants fostered an environment in which participants openly discussed reasons or justifications for changing or maintaining personal safety behaviors while driving a motorcycle (highlighted in Table 2, column 4). However, during the interviews, participants also consistently offered feedback for how the tenets of HRT could be applied to influence other motorcyclists to change risky behaviors (highlighted in Table 2, column 5). As such, the five tenets of HRT served as the foundation of the discussion between the researcher and participants.
For example, during the portion of the interview that was examining RQ1, a nonjudgmental relationship with participants was maintained. After acknowledging that motorcyclists often engage in risky behaviors and that this conversation is an opportunity to learn about those risky behaviors, we asked questions about cues to action for motorcyclists. Introducing the interview in this way created an environment for participants to share their experiences without judgment. Simultaneously, participants stated that a common reason they do not adhere to motorcycle safety messages or advice from others is because the communication surrounding their behaviors is too judgmental. Participants recommended nonjudgmental ways that future messages need to target the larger audience of motorcyclists.
Applying the metatheoretical tenets of HRT facilitated individuals' discussion of their behaviors but also offered guidance on how to consider those same tenets in changing behaviors among the larger population. For instance, participants often had comments such as “you need positive reinforcement” or “it depends on how the advice is presented” in regards to whether they will receive the message and consider changing a behavior. In this sense, the tenet humanistic value was an interpersonal tool to dialogue with individuals so they could openly discuss their health and safety behaviors. Humanistic value as an overarching tenet of the interviews allowed for deeper probing and understanding of participants' personal safety choices. In addition, it allowed a discussion about methods to enhance future communication with the larger population of motorcyclists.
Participants continued to exemplify the metatheoretical tenets of HRT throughout the interview. For example, participants advised that because heavy alcohol consumption occurs during Poker Runs (i.e., group rides for charities), making small changes to these events to reduce the amount of drinking is more reasonable than completely eliminating alcohol consumption throughout the day. For instance, one participant said:
Make it not bar to bar. Make it be like an ice cream stand or to a restaurant stop to stop. Or a park. It doesn't have to be bar to bar to bar but that's the draw. That's what people come for. And, I just [pause] it's just not my cup of tea. I go because it's usually a good cause and it makes money for something good but I'd rather have it go someplace else.
The tenet pragmatism provided an interpersonal tool to dialogue with participants so they could openly discuss what challenges they encounter to being safer. But at the same time, motorcyclists stated that a common reason they do not adhere to safety behaviors is based on the perception of not having control over these particular barriers. This caused participants to recommend how future initiatives need to address some of these barriers.
This dual purpose of the other HRT tenets was evident throughout the interviews, with the interviewer and the participant using the basis of each tenet to communicate with each other. The next section discusses the data analysis process in light of integrating a metatheory with a theory to guide interview methodology.
Summary of Integrated Metatheoretical Methodology
Table 2 represents an abbreviated version of this integrated approach as another way to illustrate how the overarching tenets of HRT, integrated with the components of the RHBM, informed and enhanced the semi-structured interviews with motorcyclists. Highlights of this metatheoretical framework are also discussed in response to the research questions.
A thematic analysis was used to derive codes from an HRT-inspired perspective. Performing thematic analysis, coding, and constant comparison of the data allowed for the consideration of how harm reduction may function as a metatheory and guide the RHBM in influencing perceived motorcycle safety behaviors. For a more thorough explanation of the data analysis process, consult Haas (2012). A brief overview of results is provided to depict how concepts and themes emerging from interviews about motorcycle safety support harm reduction as a metatheoretical framework guiding the components of the RHBM. We briefly draw on some results from the interviews to illustrate how the use of a metatheory may enhance various aspects of interviewing methodology with at-risk audiences. Implications for practice are briefly listed in Table 2, column 5 as well.
RQ1: Humanistic Value Informing Cues to Action
Results for RQ1 illustrated that humanistic value can serve as initial recognition of the risky behaviors that motorcyclists participate in while on the road. Instead of criticizing motorcyclists' risky behaviors, developing respectful cues to action that strive to raise awareness about safety choices and behaviors would be better received by motorcyclists. For example, family members who ride motorcycles were perceived as being more experienced and credible and having a stronger influence on participants' behaviors. Motorcyclists/family members acknowledge that the participant engages in a risky behavior, and instead of criticizing them, they try to offer supportive advice. Participants said that if messages are negative, judgmental, or critical of them and their behaviors, they do not acknowledge the person or advice.
RQ2: Pragmatism Informing Perceived Benefits/Barriers
Results for RQ2 indicated that pragmatism can encourage motorcyclists to be realistic about their risky behaviors and their ability to reduce perceived barriers. Results revealed a pattern of more perceived barriers beyond their control to driving a motorcycle safer (e.g., weather, other vehicles) than perceived benefits of driving a motorcycle safer. Participants partake in harm-reducing actions, such as being aware of their surroundings, following traffic laws, and checking their motorcycle, to account for external barriers for which they have no control. However, the safer behaviors within participants' control (e.g., speed, alcohol consumption, safety gear) are the behavior changes they did not make. Participants attributed fewer perceived benefits and low self-efficacy to their resistance to personal behavior change. To aid in achieving more internal behavior changes, pragmatism might promote realistic goals and the benefits of safer behaviors.
RQ3: Immediacy/Goal Setting Informing Perceived Susceptibility/Severity
Results indicated that participants are comfortable making immediate changes in their motorcycling behaviors. For example, a personal accident or near-miss accident, or seeing or hearing about a motorcycle accident, served as cues for participants to immediately change safety behaviors. However, interviews with motorcyclists confirmed that these changes were shortlived. For example, participants said that, after they heard about a friend's motorcycle accident, they immediately put on a helmet but as time went by they eventually stopped wearing a helmet. Similarly, although participants modify their behaviors in situations that they believe are riskier (e.g., adverse weather conditions), they do not continue these behaviors when riding conditions are more favorable. Other than experiencing accidents or learning about accidents, participants did not indicate feeling highly susceptible to accidents or injuries. In response, it is necessary to determine communication strategies that can instill a sense of urgency to change safety behaviors.
RQ4: Empowerment Informing Self-Efficacy
The results for RQ4 indicated that it is important to provide a plethora of choices when negotiating how this audience can be safer. Participants acknowledged the role of the environment in creating specific barriers that increase their risk for accidents. To combat some of these barriers, seasoned motorcyclists reported making behavior changes over time to minimize their chances of an accident (e.g., starting with a smaller motorcycle and testing the motorcycle in secluded areas). This tenet can inform messages that target motorcyclists to start with smaller, simpler behavior choices they can make on their motorcycle to be safer. As motorcyclists achieve smaller behavior changes, their self-efficacy to adapt additional behaviors might increase.
Results also indicated that a more egalitarian partnership needs to exist between motorcyclists and drivers of cars and trucks. This partnership might empower each audience to dialogue and act together to improve ways to safely share the road.
RQ5: Community Collaboration Informing Formative Research and Audience Analysis
Participants felt that collaboration can construct more enabling environments to facilitate behavior change. They supported collaborating with a variety of organizations such as American Bikers Aimed Toward Education (ABATE) and institutions of higher education to help initiate cues to action, reduce perceived barriers to safety on the road, and produce materials that raise awareness about motorcycle safety. They also provided input about subgroups of motorcyclists. Participants' feedback about younger motorcyclists was consistent with previous research about the motorcycling population, including that age mediates the perceived barriers and perceived susceptibility to having an accident in addition to the perceived benefit of having more fun on the road (Elliot et al., 2003). Overall, results illustrated that fostering collaborations is an important component of a harm reduction approach to modify behaviors.
HIV/AIDS Example of Harm Reduction as Metatheory Research in Practice
Although research about motorcycle safety was our focus while exploring the role of metatheory in qualitative research, this approach can be utilized for other health and safety issues as well. To show how harm reduction can be used in combination with other existing theories and protocols, we discuss an example concerning HIV/AIDS prevention research.
HIV-test counseling is a commonly used method to promote safer sex and other harm-reducing behaviors to prevent exposure to and/or transmission of HIV. However, Mattson and Basnyat (2008) argued that initial HIV-test-counseling communication protocols lacked a genuine, empathetic, individualized approach toward clients. Despite the implementation of revised Centers for Disease Control and Prevention (CDC) guidelines in 2001 that focused on risk reduction, personal risk assessment, and skill-building activities, Mattson (1999, 2000) and Mattson & Basnyat (2008) consistently contended that HIV-test-counseling protocols were vague and were compromising an opportunity to more effectively communicate with clients. Although the revised guidelines encouraged a more tailored approach, it was difficult for counselors to incorporate because counseling sessions continued to be assessment-laden both before and after testing. In addition, as transcripts analyzed by Mattson and Basnyat (2008) indicated, because clients provided predominantly close-ended “no” responses to a majority of counselors' questions, it is possible that the clients did not trust and/or feel safe discussing their risky sexual behaviors with counselors.
In an effort to employ a more client-centered approach to HIV-test counseling, Mattson (2000) argued that HRT had the “theoretical and practical vitality to reduce the relevant harms of HIV/AIDS through HIV-test-counseling discourse that empowers and promotes clients' agency” (p. 339). HRT is a suitable fit to guide and inform HIV-test-counseling protocols because HRT promotes that individuals have choices about their health behaviors (Rosenberg, 2003). After considering the ways that the tenets of HRT could inform current HIV-test-counseling protocols, the authors proposed a framework that integrated HRT to enhance the standardized protocols.
Similar to our attraction to previous research that applied the RHBM to study motorcycle safety and harm reduction frameworks that studied various issues, Mattson and Basnyat (2008) drew upon other integrative models and strategies to conceptualize their integration of HRT into HIV-test-counseling practice. Specifically, to inform their model they referred to integrative harm reduction models by Roche, Evans, and Staton (2001) and MacCoun (1998), which focused on a collaborative, overarching approach to decreasing drug abuse. The resulting model integrated the tenets of HRT with the CDC's current HIV-test-counseling protocol to probe client's safer-sex attitudes and practices. This process was similar to how we integrated HRT tenets with the current RHBM framework to probe motorcyclists' safety behaviors. Mattson and Basnyat (2008) argued that using HRT with the CDC's current risk reduction objectives further centralized the concerns of clients by focusing on aspects of respect, empowerment, and developing and addressing immediate goals based on current barriers individuals may be facing.
Mattson and Basnyat (2008) claimed that by “infusing” HRT tenets within the HIV-test-counseling protocol, counselors become more mindful of harm reduction in their discussions with clients (p. 157) while still communicating accurate information with this at-risk audience. Examples of how they infused HRT tenets within HIV-test counseling are bulleted below.
Humanistic Value: “For HIV testing counseling, a harm reduction perspective means that the counselor would accept the client's situation and behaviors without attaching judgment, regardless of whether or not the counselor approves of the situation or the behavior” (p. 150).
Pragmatism: “During HIV test counseling, a harm reduction approach would mean counselors accepting unconditionally that individuals engage in risky behaviors and rather than eliminating the cause (i.e., unsafe sex), they would focus on minimizing the negative effects of that risk” (p. 151).
Immediacy: “For HIV testing counseling, the focus of the discussion would not be on how individuals placed themselves at risk for HIV but rather how to cope with the outcome of that behavior because of the understanding that behavior is a multifaceted phenomenon and impacts the community within which it is embedded” (p. 151).
Empowerment: “During HIV test counseling sessions this translates into the client, rather than the counselor, being the primary agent for reducing the harm of risky behaviors to self and others. The counselor mostly listens and offers healthier options for consideration by the client” (p. 151).
Community Collaboration: “For HIV test counseling, this means providing immediate, personalized care to individuals that would help curb the long-term use of community resources such as mental health and other health care services” (p. 151).
This example showcases a different health topic and situation in which HRT can be used to guide and improve an already existing protocol that had not achieved optimal behavior-change success in the past. In addition, this example also illustrates that HRT can be used to guide an additional communication protocol other than the RHBM described throughout this article. This example, like our research project, illustrates that a broader, metatheoretical framework can be used to better gather, organize, and analyze data with respect to a particular theory and/or model. Examples of additional health-related topics to consider for metatheoretical integration are suggested in the following section.
Implications for Future Areas of Qualitative Health Research
Previous research suggests that harm reduction self-efficacy varies based on the type of high-risk situation being studied (Phillips, 2005). Therefore, it is important to acknowledge that using the tenets to guide a different health communication theory surrounding a different health issue may result in new themes and subthemes about the at-risk audience being studied. In response, future research should employ harm reduction as a metatheory, continuing to focus on a variety of health issues, to ensure this addition to qualitative research continues to enhance the interviewing process.
To further harm reduction as a metatheoretical framework that can inform interview methodology, future research should address controversial issues, such as needle-exchange programs or other drug-abuse-prevention programs, to determine if similar results are rendered. Motorcyclists seldomly had to discuss illegal behaviors they participated in while driving a motorcycle. The only unlawful behavior motorcyclists mentioned was going over the speed limit and/or consuming alcohol beyond the legal blood alcohol content limit. Revealing these behaviors is much different than an individual discussing their methamphetamine, heroin, cocaine, or other drug use, since possessing these drugs is a felony. Therefore, although the use of harm reduction tenets helped motorcyclists discuss their perceived safety behaviors, applying these same tenets may not render consistent results when drug users or other individuals engaging in illegal and/or socially-stigmatized behaviors are the target audience. Research focusing on different, more at-risk populations likely will provide more insights.
In addition, besides focusing on problems that are externally visible to the public, future research should address self-harming behaviors that are easier to hide, such as eating disorders and intentionally cutting oneself. It is possible that at-risk populations that can hide their risky behaviors more easily may respond differently when probed via the five tenets of harm reduction. It is possible that by incorporating the metatheoretical tenets of HRT to guide conversations with drug users or other at-risk populations, additional information will be revealed by the target audience that contributes to the development of new messages and interventions for these groups.
Conclusion
This research project demonstrated how researchers can integrate harm reduction, a known theory, as a metatheory to inform an existing health-behavior theory to help develop an interview protocol and facilitate interviews with participants. As our debriefing of the interviews and results indicated, this integration between metatheory and theory can facilitate a communicative relationship between researcher and participant and encourage richer, honest dialogue throughout the interview. We also demonstrated how integrating a metatheory with theory to inform interviews with participants can encourage the researcher to listen to participants to understand why and how they practice risky behaviors. In addition, we provided examples of how participants apply the concept of each harm reduction tenet to provide guidance for communicating with other target audience members. Based on this experience, we advocate for the use of harm reduction metatheory to guide theories and interviews in future research projects and for the continued exploration of the role of metatheory in qualitative research.