Building Connections While Conducting Qualitative Health Fieldwork in Vietnam

Abstract

Researchers are increasingly embarking on international qualitative health research projects, where unknown social structures and government systems make inquiry uniquely challenging. In this article, we document our experiences conducting two related studies on HIV/AIDS in Northern Vietnam. We describe how our research relied on harnessing the social capital of vital community stakeholders, such as key informants, interpreters, and host organizations, to effectively engage with government bodies on a macro level and with local communities on a microlevel. By highlighting our processes, pitfalls, and successes, we provide current and future scholars with strategies to use when conducting cross-national field research.

Introduction

Each year, an increasing number of qualitative researchers of all ages, backgrounds, and education levels embark on international fieldwork. Foreign locales provide many opportunities to learn about unfamiliar modes of human behavior and to decipher innovative ways to solve various health or human rights crises. With these exciting prospects come a number of unique and unforeseeable challenges that are rarely encountered by those who conduct research domestically (Adams, Miller, Craig, Le, & Varner, 2007; Hubbell, 2003; McMillan & Conlon, 2004). Social and cultural issues are at the forefront of these challenges. Other complications stem from difficulties with logistics, communication, transportation, politics, and a lack of resources (Mukeredzi, 2012). Despite the numerous qualitative studies being conducted abroad, there are a limited number of articles discussing the challenges and setbacks facing researchers who undertake cross-national field research.

The purpose of this article is to describe the authors’ experiences overcoming obstacles that we faced in conducting qualitative research projects that studied the ramifications of HIV/AIDS in Northern Vietnam. We rely on the concept of social capital to analyze our experiences building connections in the context of international fieldwork. Traditionally, social capital is used to examine and explain the development of resources and value within an existing community (Burt, 2000). However, as cultural outsiders—known as bà tây in Vietnamese—we were challenged with gaining access to and earning the trust of hard-to-reach communities on the microlevel and government authorities on the macro level. Through our relationships with interpreters, key informants, and the international nongovernmental organization (NGO) that served as our host organization, we were able to successfully complete our research projects and assist in the development of interventions for communities affected by HIV/AIDS. Without our collaborators’ willingness to grant us access to and engagement with their existing social capital, none of this work would have been possible. We use this article as an opportunity to share our experiences with other researchers who may benefit from building and harnessing social capital with the stakeholders involved in their projects. We also explore the limits of harnessing the social capital of our project partners, recognizing that our ability to build connections is constrained by length of time in the field as well as language and cultural barriers.

Our article begins with the groundwork of our theoretical framework. We then describe the collective, negotiated system of social capital that we engaged with in Vietnam, namely, the macro level and the microlevel as well as a third meso level that formed in between. Next, we present individual case studies that outline how we independently relied on the social capital of the various organizations and individuals that we worked with in order to get our research approved and completed. We end with a critique of our experiences and interactions, including implications for future scholars seeking to do similar international qualitative work.

Theoretical Framework

Social capital—or Vốn Xã Hội—is a topic that spans across several disciplines, including the social sciences and public health. Social capital is defined as the accessibility and availability of public resources through participation in the community, which can be gathered to benefit the individual (Burt, 2000; Woolcock & Narayan, 2000). It can also be described as the web of cooperative relationships among citizens which facilitates resolution and collective action taken against problems. This involves various aspects of social structure, such as levels of interpersonal trust and norms of reciprocity and mutual aid, which act as resources to be shared. Important components of social capital are civic engagement in the community and transactions with community members (Bourdieu, 1990; Coleman, 1988; Putnam, 2001). Some requirements of social capital are that the individual’s relationship with the community span over a long period of time, be subconscious or internalized within the connected individuals, and have consequences such as trust or loss of trust based on several relationships (Paxton, 2002). The concept of social capital relies on the shared experiences of a community over time. As such, within the context of international research, obtaining social capital can be a daunting and potentially impossible task, especially with short-term projects and language barriers. By working closely with host organizations, key informants, and interpreters, we were able to overcome these barriers and harness the social capital of our partners in order to achieve our research goals.

Description of Projects

First author’s study looked at the impact of HIV-related stigma and discrimination on children’s entrance into the Vietnamese school system. Second author’s study analyzed the role, context, and coping mechanisms of grandparents raising orphaned grandchildren affected by HIV/AIDS. Our projects included 4 months and 9 months, respectively, of data collection in Vietnam. We met through working at the same international NGO located in Northern Vietnam, although our studies contributed to the development of different interventions. First author’s research contributed to campaigns to integrate children living with HIV/AIDS into public schools. Second author worked on the development of empathy clubs for grandparents raising grandchildren in the wake of the AIDS epidemic. Both of the researchers obtained the approval of the institutional review board (IRB) at their home institutions. First author received additional approval from the Hanoi People’s Committee and the Ba Vi, Hanoi, and Ba Dinh, Hanoi school districts. Second author received additional approval from the Department of Foreign Affairs and the Security Force of a city in Northern Vietnam.

Social Capital: The Microlevel

One important aspect of conducting an international qualitative research project is locating trustworthy and reliable key informants and interpreters having strong connections with the population (Hubbell, 2003; Mack, Woodsong, MacQueen, Guest, & Namey, 2005; Temple & Edwards, 2002; Yach, Mathews, & Buch, 1990). Key informants are defined as local individuals who are willing to provide essential information about the population of interest. They assist the researcher in developing an understanding of the community at a quicker pace than the researcher could achieve on his or her own. This is essential when working on a project abroad because time spent in country can be scarce and pilot studies may not always be feasible. Interpreters can connect the researcher to the population of interest, help inform the design of the study, and at times develop into the role of coresearcher. During the course of both of our projects, we worked in partnership with key informants and interpreters to ensure the validity of the research methodology and interview guides.

Social Capital: The Macro Level

Before traveling abroad, investigators should develop an understanding of the host country’s government structure. One of the more unanticipated aspects of our studies was the high level of government engagement needed to conduct our research. The government ministries that were most relevant to our studies were the Ministry of Health (MOH) and the Ministry of Education and Training ([MOET]; Cima, 1987). Local governments in each province also play a major role in governing the country and, in our experience, function somewhat parallel to the national ministries.

It is common for international researchers to experience resistance from local and national government systems when trying to implement health research projects that involve sensitive subjects such as reproductive health or HIV/AIDS (Stenson, Kapungu, Geller, & Miller, 2010). We experienced significant setbacks due to our lack of knowledge about Northern Vietnam’s government landscape prior to entering the field. We had few contacts to turn to during the planning stages, as we were unaware of any other researchers conducting studies in Northern Vietnam prior to traveling abroad. Second author was able to connect to three researchers conducting projects in Southern Vietnam, but information was regionally specific and every province handled international researchers using their own unique protocols. Additionally, because we did not expect that obtaining government approval would be such a critical and time-consuming component of our work, we did not spend enough time inquiring with our host organization and key informants about Northern Vietnam’s government landscape before traveling abroad.

Social Capital: The Meso Level

We consider the meso level of social capital building to take place in any situation that involved the intersection between key informants and the government. For our projects, our mutual host organization, an international NGO, facilitated these relationships. Finding a local host organization that is invested in the researcher’s topic is a necessary step that should be taken prior to traveling abroad. It is essential as a cultural outsider to associate oneself with a foreign institution when beginning an international study, particularly in terms of developing local contacts (Hubbell, 2003) and legitimizing oneself with the local government officials. The process of finding a host organization and cultivating a mutually beneficial working partnership was vital to the success of our projects. Local host organizations can help researchers find key informants, obtain government approval, assess the cultural appropriateness of questionnaires and other research materials, and overcome unforeseen problems that might occur once research begins.

Two Case Studies

Below, we describe two case studies that illustrate collaboration between various parties in order to engage with communities in northern Vietnam to conduct research related to HIV/AIDS. We each detail how we worked on the microlevel, macro level, and meso level of social capital and relied on our connections within each of these layers to get our projects approved, off the ground, and successfully completed. We also critique our processes, describing particular situations where the notion of harnessing social capital was not feasible due to limitations of outsider status, language, and culture.

Case Study #1: A Mixed-Methods Inquiry Into Stigma and Discrimination Against Children Living With HIV/AIDS

The first author’s study investigated parental resistance to the integration of HIV-positive orphans into public schools in Hanoi. This issue was relevant to her host NGO’s work on reducing stigma and discrimination targeted at children living with HIV/AIDS.

Microlevel: Seeking key informants and interpreters

Key informants helped first author understand Vietnamese culture and the government processes involved with her research project. Many of the connections facilitated and cultural understandings clarified by her key informants were not obvious to her as a cultural outsider. For instance, without her primary key informant, she would never have known that she needed to connect with the provincial Vietnamese government officials at her study sites. In this respect, the key informants served as gatekeepers to valuable information. They used their personal connections and insider knowledge to serve as liaisons between first author as the researcher and her target population (Mack et al., 2005).

In a similar way, first author found that her interpreters became important members of her research team by working patiently with her as her study evolved during the time she spent in country. She found her interpreters through students at a local university, and hired and trained them in the weeks leading up to beginning her interviews. A researcher’s partnership with interpreters is a mutual learning process that undergoes several stages, from making the initial connection to critiquing each other’s work to providing final feedback on the results of the study (Harris Boggiano, & Nguyen, 2013). The interpreters not only made it possible to communicate with study participants (Squires, 2008) but also served as cultural ambassadors (Temple & Edwards, 2002) and organized logistics for travel and interview locations.

In addition to oral and written translation assistance, first author’s interpreters kept her out of “trouble” during cultural misunderstandings. For instance, additional family members would often try to participate in interviews because they were unfamiliar with the requirement of confidentiality in Western research projects. In these instances, the interpreters not only repeated the procedures of the studies to the participants but also explained why Vietnamese family members wanted to be involved in the process. They assisted in creating appropriate solutions for how to respect the privacy of the interview. For instance, first author and her interpreter would often provide games for the children and family members to play during the interview and reserved time at the end of each interview so that family members could ask questions about the study, her work, and her home country. First author’s interpreters also informed her that she should avoid contacting research participants over the Tet holiday, Vietnam’s New Year, which fell shortly after the project received approval from the Vietnamese government.

Macro level: Navigating Vietnam’s government structure

In order to gain access to her study population, the first author had to engage with several levels of the local and national Vietnamese government, which formed the macro level within which she worked. The first author’s research participants were parents of children attending six primary schools in Hanoi, three in a rural district and three in an urban district. To recruit participants, she needed to obtain lists of all students and parents in each of the schools, which required government approval. Once in country, the actual approval process took 3 months. Were it not for the diligence of her key informant and her interpreters frequently communicating with their government contacts, it would likely have taken much longer for first author to begin her study.

Working with the Vietnamese government as a “bà tây” is a complicated process. Because her research was related to HIV/AIDS, the first author’s key informant initially put her in touch with someone from the Hanoi Centre for HIV/AIDS Prevention and Control (Hanoi PAC), underneath the Hanoi Department of Health and the Vietnam Authority of HIV/AIDS Control. The person she met with at the Hanoi PAC sent her to the Hanoi Department of Education and Training, who then sent her to the Hanoi People’s Committee (Hanoi PC). Her key informant had a connection to the Foreign Affairs Office of the Hanoi PC who helped her obtain project approval by first the Foreign Affairs Office and next the director of the Hanoi PC. The first author carried her approval documents with her at all times. Nearly each of her 60 participants asked to see the approval documents at the start of the interview, and there was one instance where a local government official in Ba Vi, the rural district she worked in, appeared at one of the interviews and asked to see the approval documents before she could continue. Overall, the first author and her interpreters and key informants spent a great deal of time working within the macro level of the Vietnamese government to complete her project.

Meso level: Establishing relationships with host organizations

In the interplay between key informants and the government is the host organization. The first author worked most closely with an international NGO that served as her primary host organization. This NGO helped first author receive approval from the Vietnamese government and also helped her analyze the transcripts she collected throughout her interviews. After her research was complete, the international NGO and the first author organized a camp that utilized the results of the study to educate parents about the realities of HIV and AIDS transmission. Prior to connecting with her primary host organization, the first author was able to contact a local Vietnamese NGO with the help of one of her colleagues. The local NGO served as a second host organization by assisting her with planning the study design, securing a work visa to conduct research in Vietnam, and obtaining approval from the Vietnamese government and her university’s IRB.

A relationship with host organizations can be difficult to establish. Problems may be avoided by thoroughly vetting host organizations before traveling abroad and by having several conversations to ensure that the study is mutually beneficial. Even when several conversations take place prior to the researcher arriving in country, this relationship can be complicated. The relationship between the first author and one organization dissolved due to political issues. Before arriving in Vietnam, the first author spent several months communicating with a professor at the university she had initially intended to partner with. When first author arrived in Vietnam, the professor stopped responding to e-mails and phone calls. First author went to the university to speak to the professor in person. During the conversation, the professor stated that she had been told by administrators at the university that she was not able to collaborate with an American on a research project. There was a recent incident where a different American researcher had tried to partner with the university and had been dishonest about his or her real identity. This incident made the university hesitant to collaborate with Americans on future research projects. When the first author’s relationship with the university fell through, she relied on her contacts in Northern Vietnam, as well as at her home university, to establish connections with the international and local NGOs that ended up serving as her primary and secondary host organizations, respectively. If it were not for the first author’s ability to remain flexible and stay in the country long enough to develop another partnership, the entire research project would have been in jeopardy.

Case Study #2: An Ethnographic Study of Grandparents Raising Grandchildren in the Wake of the HIV/AIDS Epidemic

Microlevel: Developing culturally sensitive and appropriate interview guides

As a researcher, the second author felt that she benefited from discovering where the interviewee took her during the interview, rather than following a specific set of questions in an interview guide. Because the second author used an ethnographic approach in her research, it was essential that the design of the research continued to evolve while in the field and that both participant (emic) and researcher (etic) views were reflected throughout the research process (Denzin & Lincoln, 2000; Helfrich, 1999). This allowed for in-depth and flexible interviews, which are required when undergoing ethnographic investigation (Janesick, 2004; Manning, 1997; Michalowski, 1996).

Throughout the course of the study, the second author asked her interpreter, the third author, for feedback on how he thought each interview went. During these conversations, we discussed the execution of the questions, interview style, and cultural appropriateness. For example, it became clear during the first 5 interviews that the grandparent participants were not responding to the word “coping.” When asked how they “coped” with raising their grandchild due to the AIDS-related death of their adult child, often they would reply that “they did not know.”

The Vietnamese word for “coping” is “ứng phó,” which means “to deal with” or “to handle.” Although there is a direct Vietnamese translation, the word ứng phó sounds very academic and is rarely used in rural communities and among the older generation. The third author and the second author discussed this problem in depth and came up with a solution: The entire question needed to be rephrased to ensure that we were getting at the crux of the question. Therefore, third author translated, “How do you cope with the situation of raising your grandchild due to the AIDS-related death of their adult child?” into “Taking care of your grandchildren without the support of their parents, you must have a lot of difficulties. So how do you manage the difficulty of taking on the role of primary care giver of your grandchildren?”

Third author’s knowledge of the local language and culture made it possible for the second author to learn about how grandparents “managed” their everyday lives, which revealed several coping strategies. By asking participants about role management and their caregiving routine, we were able to elicit meaningful and rich information.

Macro level: Navigating government approval

We found that having key informants who had knowledge of the appropriate channels of approval from the government was key to the success and execution of our fieldwork. The key informant involved with the international NGO that worked closely with second author stressed the importance of having transparency and clearance in all steps of applying for and receiving government approval for research projects. For example, in Vietnam, the government must be aware of daily fieldwork activities, especially when said work is being carried out by a bà tây.

On many occasions, grandparent participants would agree to take part in the study and requested an interview the following day. In order to make the interview happen, and not lose the participant in the study, the second author would often panic about not receiving approval from the local government in time. The key informant was often able to obtain government approval the night before because he had personal relationships with the local government officials. This familiarity enabled him to access appropriate government channels in a short amount of time, although it may have had negative consequences for him if the project was not carried out with cultural sensitivity and respect for the system.

Meso level: Ensuring reciprocity and mutual benefit

The second author was able to work on the meso level of social capital through ensuring that her study was going to be mutually beneficial to the community and the NGO. For example, researchers should strive for a partnership that promotes cultural understanding and educational opportunities among all parties involved in the project. Conducting research that is collaborative and reciprocal will increase the possibilities of a long-term relationship and a sustainable project outcome (Israel, Schulz, Parker, & Becker, 1998).

Over the course of the second author’s research project, she was given the opportunity to facilitate various workshops for grandparent caregivers, government officials, home-based caregivers, and local NGOs on the findings of her research. In addition, she gave several sessions based on an “international” perspective on kinship care, including a synthesis of research from the United States, Africa, and Southeast Asia. As a researcher connected to a university outside Vietnam, she was able to provide outside resources and information. Additionally, her background as a social worker was useful when training home-based caregivers on how to integrate services for grandparent caregivers into preexisting programs for orphaned and vulnerable children. Establishing mutual benefits in the initial stage of the project ensured that both parties worked together throughout a project, from development to dissemination.

Discussion and Recommendations

By harnessing the social capital of our research partners, we were able to successfully complete two qualitative studies in Vietnam. We remained open and flexible, trying to satisfy the needs of our research institutions in the United States while staying attuned to the intricacies of the local culture within which we worked. We believe that there is much to be gained by working so closely with local key informants, interpreters, and host organizations. Yet at several points throughout this process, we questioned if full collaboration as cultural outsiders was truly possible. We continue to reflect on whether one can fully harness the social capital of short-term community partners. In the discussion subsequently, we critique our experiences and discuss our findings in relationship to other literature in which researchers have engaged in cross-national and cross-cultural fieldwork.

In order to establish connections at the microlevel of social capital, all persons involved in conducting a study need to determine their collective goals, lay out their roles and tasks, and learn to trust and support one another over time (Stenson et al., 2010). We found that working alongside qualified and dedicated interpreters as coresearchers helped us to establish connections to the community, not only when working toward the mutual goals of the project but also when developing study tools and during the analysis and dissemination phases of our studies.

Despite the success of our relationships with our interpreters, there are several potential drawbacks to elevating interpreters to the level of coresearchers. Possible bias in the interpreters’ questions or participants’ responses as well as the fact that some research concepts may be unfamiliar to interpreters who have less practice in doing fieldwork. In addition, the use of an interpreter adds a third party to the typical researcher–participant dyad, which can have negative consequences such as increased amount of errors and decreased comprehension (Karliner, Jacobs, Chen, & Mutha, 2007). These drawbacks can be lessened through training interpreters in the goals of qualitative research as well as spending time before, during, and after each interview reflecting on the partnership and the process. Other reflections on interpreter–researcher relationships note that this unique partnership requires trust and flexibility and a keen awareness of one’s own communication style (Lee, 1997). In order to carry out research that is culturally competent, while addressing a sensitive topic, such as HIV, the partnership needs to continuously revisit the purpose of the research, the delivery of questions in the interview, and discuss the unexpected and unusual aspects of each interview (Harris et al., 2013).

One of the most laborious aspects of each of our studies was the interaction with the Vietnamese government. The structure of Vietnam’s government system requires the researcher to gain approval at many levels—from the local wards up to the central bodies that govern the country (Cima, 1987). This takes dedication not only on behalf of the researcher but also on the part of the key informants and interpreters assisting in gaining approval. Mathee et al. (2010) share their experiences in working with government officials when they conducted a research project in South Africa. They stress the importance of making partnerships with government and community stakeholders, as this helped them gain access to study sites, ensure participation in early stages of the research, and engage the community in postresearch next steps. In Vietnam, we found that such relationships are, at times, difficult to establish. Few researchers come to Vietnam to conduct qualitative studies related to such sensitive topics as HIV/AIDS.

Reflecting on both of our studies, we realize that we could have connected earlier to our host organization while planning the project in the United States, in order to have early discussions about government involvement. That way, government channels could have been paved well before we arrived in Vietnam to begin our projects. We recommend that researchers work closely with their host organization, key informants, and interpreters to map out the appropriate channels of approval and intentionally work with a team that is willing to be persistent, despite setbacks from the government.

We also caution, however, that there can at times be selection bias with regard to finding the key informant, upon whom the researcher often relies heavily. If host organizations are the ones selecting the key informants, they may choose the individual who speaks the best English, is the most connected to Western culture, or has the best inroads with the country’s government. These qualities may not make a particular individual the right key informant for the international researcher’s project. To circumvent this problem as much as possible, the researcher should be closely involved in selection of the key informant and might even consider informally interviewing several candidates before selecting one or two primary informants to assist the researcher most closely throughout the project.

One of the ongoing ethical challenges for an international researcher is entering, engaging in, and exiting the field in a culturally appropriate way. We believe that facing this challenge through continuously revisiting ethical dilemmas and mutual benefits throughout our research solidified the methods of our projects and offered sustainable benefits to the organization and the participants (Stenson et al., 2010). Our relationship with the NGO that hosted us was invaluable in terms of providing both cultural information and partner projects that made our research relevant and needed. The researcher and the NGO should predetermine what tangible contributions will comprise the “deliverables” for the population participating in the research, the NGO, and the researcher.

Working alongside an international NGO privileges the researcher to build upon the work that has already been established in the community prior to their study. For this partnership to be successful, both parties need to engage in a team approach and communicate clearly about their needs and goals (McMillan & Conlon, 2004; Stenson et al., 2010). We learned from our partnership and our research that the development of an outside intervention from the West was not necessary to make an impact in the community. Instead, we relied on contributing to the development of local intervention. With the assistance of our collaborators at all levels, we were able to incorporate community theories, participation, and practices into our research practices (Wallerstein & Duran, 2006).

Despite the many noted positive aspects of our relationship with an international NGO, there were also several drawbacks to this partnership. We found that participants often mistook us as NGO workers instead of researchers, even when we introduced ourselves as researchers connected to universities and explained the purpose of our studies. This dynamic likely influenced the ways that participants responded to our questions. On occasion this led to the expectation of aid in connection to the project, when it was made explicit that this was formative research that was not yet connected to an intervention at the time of our fieldwork.

In addition, we were connected to our host organization’s HIV sector. Our mutual beneficial project goals with our host organization had already been established as HIV care and stigma reduction, which may have silenced some of the main concerns of our participants. Moreover, we quickly realized that HIV was often not the most pressing concern in the lives of our participants. Rural grandparents were often more concerned about funding an education for their grandchildren, providing food and securing future care for the time when they could no longer provide it. Parents in the Vietnamese school system were often more concerned about the quality of their children’s education than the HIV status of their children’s classmates.

Overall, the government, the staff at the NGO, as well as our key informants and interpreters, viewed us as outsiders, given the short duration of our stay in Vietnam. Because they saw us as being only temporarily in country, this could have caused our project partners, as well as our participants, to question the sustainability of our work, thereby eroding the collaboration process and undermining the concept of social capital itself. In the beginning of our projects, we explained that we would remain committed to working on health-related initiatives in Vietnam and have continued to engage in new research initiatives and evaluate the interventions that we helped to establish.

Conclusion

Our time in the field exposed us to unforeseen variables that threatened to severely delay or terminate the research. At times, first and second authors’ experiences (both positive and negative) were the same; in other instances, they differed drastically. Researchers are presented with several obstacles when performing cross-national field research. Challenges include (1) managing linguistic and cultural issues, (2) gaining consent and approval from the government, and (3) finding partner organizations to support the research.

Through documenting how we attempted to navigate Vietnam’s cultural and administrative landscape and successfully complete our work, and addressing the challenges that we encountered along the way, we reflect on the unique situation of trying to utilize the social capital of key stakeholders in the community on microlevel, macro level, and meso level. In so doing, we hope that our experiences will provide valuable information on how to undertake international projects in Southeast Asian countries as well as to shed light on some circumstances that may arise when conducting qualitative research in any non-Western country.