Abstract
Exploring constructions of mental health in the perinatal period among Indian immigrants can be challenging. This article describes the use of visual methods, photo elicitation, free listing and pile sorting, as an adjunct to face-to-face interviews to understand the constructions of perinatal mental health among Indian immigrants in Australia. The benefits and challenges of using these methods and modifications made during the research are explained. The modifications resulted in a broader understanding of terminology used by the Indian community. Incorporating visual methods as an adjunct to interviews when discussing perinatal mental health with Indian immigrants is effective and using multiple methods enhances the richness of data.
Introduction
In a culturally diverse healthcare setting, gathering information about sensitive topics can be challenging (Donnelly et al., 2011; Thomson et al., 2015). Increasing number of researchers are using novel arts-based approaches to aid data collection on sensitive topics to engage groups that are often excluded from research, such as migrant and refugee communities who do not speak the dominant language (Ortega-Alcázar & Dyck, 2012). In-depth interviewing is a common approach to collect data on participants’ perceptions and experiences of their world and is particularly useful when researching sensitive issues (Elmir et al., 2011). Interviewing is a valuable method in qualitative research that helps explore an individual’s constructions of their experiences (Cohen et al., 2011) and examines people’s viewpoints in greater depth (Kvale, 2003). However, some topics such as those related to sexual and reproductive health issues (Mengesha et al., 2017), mental health problems, domestic and family violence (Rollans et al., 2013a) and terminal illness and death (Hines-Martin et al., 2019) are potentially sensitive, as in some cultures discussing certain topics is taboo. For example, in Indian society, mental illness is rarely discussed openly (Leung et al., 2012; Rao et al., 2019; Schmied et al., 2017). Conditions such as postnatal depression may not be accepted as a clinical condition in some cultures, and women have reported experiencing stigma and judgement as a result of their condition (Jain & Levy, 2013). This stigma could be a barrier in the diagnosis and treatment of postnatal depression in the Indian population.
Traditionally, psychosocial assessment of pregnant women in New South Wales (NSW) Australia is conducted with a structured questionnaire in English and screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987). Studies have shown that women who do not use English as their first language and who belong to different cultural groups may not disclose issues related to mental health (Rao et al., 2019; Rollans et al., 2013b). This suggests that more culturally relevant approaches to conducting psychosocial assessment for different cultural groups, such as the immigrant community, are needed. Similarly, different research techniques may also be required as an adjunct to interviews to initiate dialogue about sensitive or taboo topics, such as perinatal mental health.
In research, there is an increasing reliance on the use of techniques such as photo elicitation (Shannon-Baker & Edwards, 2018), photo voice (Leung et al., 2017), Q sort or pile sorting (Yeh et al., 2014) and free listing (Antin et al., 2015) to facilitate in-depth data collection for sensitive topics. Studies have shown that use of these techniques, along with interviews, can result in richer data and validate the research findings from in-depth interviews (Alshenqeeti, 2014; Ho, 2006).
This article will describe the use of different methods, namely, photo elicitation, free listing and pile sorting, which were used by the researchers alongside in-depth interviews in a study exploring the constructions of mental health in pregnancy and after birth by immigrant women and men. As outlined below, participating women and men were invited to an in-depth interview with the researchers. Following a period of introductions and rapport building, the interview commenced in a more traditional form, inviting participants to respond to a series of open-ended questions about their experiences of becoming a parent in Australia. In the latter part of the interview, the techniques of photo elicitation, free listing and pile sorting were introduced to participants in that order. This decision to include these methods in the latter part of the interview was made by the research team to gather other data that were not elicited throughout the interview, and with the intention of not having the interview driven by these methods. This paper discusses these methods and examines the benefits and challenges faced by the researchers during the use of these methods.
Background to the Study
Mental health problems in the year before and after birth (the perinatal period) are a significant public health issue (Kingston et al., 2012; Westall & Liamputtong, 2011; Woolhouse et al., 2015). Around 13–16% of women will experience major depression during pregnancy, increasing to around 22% in the first 12 months postpartum (Okagbue et al., 2019; Wisner et al., 2013). It is concerning that rates of postnatal depression for women who are immigrants and refugees are considerably higher than non-immigrant populations in high-income countries such as the United Kingdom, Canada and Australia (Eastwood et al., 2011; Falah-Hassani et al., 2015). Some reviews suggest that postnatal depression (PND) may affect between 20 and 42% of immigrant women (Collins et al., 2011; Falah-Hassani et al., 2015).
In order to understand the constructions or meanings of perinatal mental health among Indian immigrants now living in Australia, the authors conducted in-depth interviews with couples of Indian origin living in Australia, who were either expecting or have had a baby recently. Mental illness is a major health problem in India (The World Health Organization [WHO], 2017) and contributes to significant economic and psychosocial burden. In India, depression affects an estimated 57 million people (World Health Organization (WHO), 2017). In spite of a high prevalence of mental illness, help seeking for mental health problems is very low in India, predominantly due to fear of being shamed and the dishonour that disclosure of mental illness will bring to the individual and family (Gilbert et al., 2004; Kapadia et al., 2018). In a recent survey conducted across eight major cities in India, it was found that even though the participants showed high awareness of mental illness (87%), they also reported a high stigma against people with mental illness (The Live Love Laugh Foundation [TLLLF], 2018). This was demonstrated in the survey by terms that the participants associated with mental illness, such as ‘crazy’, ‘mad’, ‘talking to themselves’ and ‘prone to violence’.
Identifying women with perinatal mental health problems is challenging, not only in India, but also in many high-income countries. Lack of disclosure is the key barrier to treating and supporting women with perinatal mental health problems (O'Mahony et al., 2012; Schmied et al., 2017). The most common challenges to disclosure are reported as stigma, shame, fear of being labelled, the expectations from society about being ‘a good mother’, fear that disclosure may result in the infant being removed from them and lack of time to engage in treatment and language barriers (Brown & Lumley, 2000; Callister et al., 2011; Dennis & Chung-Lee, 2006; Schmied et al., 2016).
Given that perinatal mental health problems are prevalent worldwide, there is debate about the best methods to identify and support women with mental health problems in pregnancy and after birth. Increasingly, countries like Australia are implementing routine psychosocial assessment by midwives in pregnancy and by child and family health nurses in the community after birth. For example, in New South Wales (NSW), routine psychosocial assessment is conducted with the use of EPDS and a defined set of psychosocial assessment questions (Schmied et al., 2011). Analysis of this data collected from one hospital in Sydney indicated that the prevalence of a EPDS score ≥13 is higher in women born in India than in all other groups of women; however, very few of the women born in India disclosed existing or previous mental health problems, domestic violence or family problems (Dahlen et al., 2015). In other research conducted in NSW, observations of psychosocial assessment conducted by midwives demonstrated that women from culturally and linguistically diverse (CALD) backgrounds reported the questions were sensitive and they were reluctant to answer them (Rollans et al., 2013a). Both these studies indicate the need to improve identification of perinatal mental health issues, particularly among CALD women. Researchers have argued that a more culturally relevant approach to conducting psychosocial assessment in the immigrant community is needed (Willey et al., 2019).
In this article, we discuss methods from the study titled, ‘Vatsalya’ (affection). This is a mixed method study using an exploratory sequential design. To ensure the study design and methods are appropriate for the immigrant Indian community, we established a study community stakeholders’ group (CSG) with diverse representation from the Indian community in Sydney, Australia. Phase one comprised an in-depth exploratory study of women’s and men’s perceptions and experiences of perinatal mental health. The findings from phase one will be used to inform a survey in phase two. In designing this study, one of the challenges the research team faced was how best to interview people about sensitive issues that are rarely spoken of or are taboo in other cultures. To address this issue, multiple methods were considered and implemented for the qualitative phase of this study, including photo elicitation, free listing and pile sorting. As data collection progressed, the researchers faced certain challenges and modifications were made to the techniques used. This article elaborates on methods and challenges faced in using these methods in this study.
In order to capture participants’ constructions of mental health and mental illness in the perinatal period, as well as their experience/perception of the universal perinatal psychosocial assessment process and services, we recruited women and men who were born in India and had emigrated to Australia in the last 5 years. In addition, the women and men were expecting their first or subsequent baby or were parents of a baby under 6 months of age. Participants were recruited using the snowballing method, with an aim to include participants from different states of India. We conducted one face-to-face interview with both the woman and her partner, separately if possible or, if preferred, as a couple. In some instances, the male partners did not wish to participate or were not available to participate. In total, 17 migrants from India living in Australia participated in the study. Six couples (women and men) participated and all of them preferred to participate together and not in two different interviews. Of the five women who participated without their partners, three partners were not available and two did not wish to participate.
Each participant (either the couple or the woman alone) attended only one interview. These interviews were conducted between January 2018 and October 2019. Towards the end of the semi-structured interview, the participants were invited to talk about a photograph that depicted topics related to parenthood. Following this, they were provided with a list of words and phrases generated through the free listing process (described in the following section) and were asked to sort these words or phrases into two piles according to their understanding or concept of mental health and mental illness. During the first four interviews undertaken by the researcher, participants were encouraged to add to the list of words and phrases about mental health and mental illness, but none of the participants provided any new words or phrases. As a result, subsequent participants were not asked to add to the list of words or phrases, and none offered any additional words.
Approaches to Data Collection
Photo Elicitation
Photo elicitation is the use of one or more photographs as a stimulus during an in-depth research interview (Meo, 2010). Collier first used the term photo elicitation in 1957 and used photographs to study the influence of environmental factors on mental health outcomes (Collier, 1957). Since then, photographs have been used for research in the fields of anthropology (Bignante, 2010; Clark-Ibáñez, 2004), education (Meo, 2010; Pyle, 2013; Smith et al., 2012; Torre & Murphy, 2015), health (Balmer et al., 2015; Oliffe & Bottorff, 2007; Ortega-Alcázar & Dyck, 2012) and marketing (Andersson et al., 2016; Matteucci, 2013). Through the use of photographs, the researcher attempts to gain insight into the world of the participants (Barbour, 2014; Torre & Murphy, 2015). Use of photographs has proven to be valuable when studying vulnerable groups such as children (Mandleco, 2013), homeless persons (Padgett et al., 2013), marginalised groups (Minthorn & Marsh, 2016) and persons from different cultures (Ali-Khan & Siry, 2014). Photo elicitation has also been used to overcome language difficulties and cultural barriers (Peroff et al., 2019).
Photo elicitation aims to activate memories and responses among participants and help them share their attitudes, outlooks, views and meanings or to examine subtleties of the group (Meo, 2010). People respond differently to verbal and visual information because ‘parts of the human brain that process visual information are evolutionarily older than the parts that process verbal information’ (Harper, 2002, p. 13). The use of photographs in interviews can also act as a bridge between the researcher and research subjects’ social and cultural worlds (Meo, 2010).
Use of photo elicitation can enrich the qualitative interview in various ways (Antin et al., 2015). However, researchers have also used photo elicitation in quantitative research by using quantitative ranking of photographs (Peroff et al., 2019). Photos add value to already existing methods by bringing in another dimension (Balmer et al., 2015) and capturing rich multidimensional data (Mah, 2015). Photo elicitation can help promote understanding of culture, which may result in new views and dialogues regarding health, wellbeing and migration (Ortega-Alcázar & Dyck, 2012).
In this study, the participants were invited to bring to the interview some family photographs they cherished and that displayed socio-cultural practices around pregnancy and birth and/or the postnatal period. These photographs were then used as prompts during the interview to gently open up the conversation. In the interviews with the first four participating women/couples, participants brought these photographs and discussed their meaning.
One of the couples opted to present a photo relating to the naming ceremony that occurs when the baby is about 28 days old. The photo had only the mother, father, baby and maternal grandmother in the frame, in contrast to a large crowd of extended family, friends and neighbours that would have been expected if the ceremony was held in India. This photograph illustrated the importance of the ceremony and of maintaining cultural practices at the appropriate time; however, it also captured the social isolation this woman and man, and potentially other immigrant families, experience at these important times. ‘if it was in India, it would be like a big celebration with relatives from both sides of the family coming with gifts and gold ornaments, here it was just the three of us and her mum’ (participant 2)
Another couple shared a photograph of a ceremony at their home when the woman was 7 months pregnant. The photo showed her friends who came to the couple’s home to pray and bless them and share their joy. This couple stated they were very well supported by the Indian church community and hence did not feel isolated. One of the couples brought a picture taken in India of the ‘godh bharai’ (religious baby shower) ceremony of a relative. In contrast to their own celebration, this couple thought the ceremony shown in the photograph might be a burden in their lives as it would be difficult to source the cultural artefacts needed for these ceremonies in Australia.
After conducting the first four interviews, we reflected on the quality or richness of the data that was elicited from the discussion of the photographs. Although the participants readily brought photographs for the interviews, they appeared reluctant to talk in depth about their photographs. It seemed that the photos were familiar and therefore they had less to say. The data gathered with the help of participant photographs elicited information on their traditional practices and highlighted the isolation experienced by one participant. However, this did not add any information regarding the constructions of mental health and illness. Hence, we decided to try a different approach to the photo elicitation by providing the couples with a series of photographs depicting different perspectives of motherhood and fatherhood and cultural practices and beliefs common in India, such as the importance of male children. These photographs were selected using a staged process. Our review of the relevant literature identified certain beliefs and practices dominant in Indian culture that caused conflict or stress for immigrant Indian women and men having a baby in a new country (Shidhaye et al., 2017). For example, the need to maintain cultural practices, such as ceremonies, in the postnatal period is not easily accomplished in their new country and can be stressful for the new parents (Simich et al., 2009). Similarly, the cultural emphasis on birth being a time to celebrate can impact negatively on a woman who may be experiencing symptoms of depression, which is not acknowledged or recognised by her family (Wells & Dietsch, 2014). These stresses were also described by the reference group members who emphasised the impact of gender preference among some families in India (Goyal et al., 2017). Based on this information from the literature and reference group, as well as the personal cultural knowledge of author 1, a series of 20 freely available photographs were sourced from the internet reflecting these beliefs and practices. Each image was discussed with the research/supervision team and ten photographs that most clearly portrayed the concepts were selected for use during the interview. For example, one of the selected photographs depicted a mother who looked exhausted, with things out of place in her house and a crying child. Another photo showed just the words ‘it’s a girl’. The same ten photographs were then shown to each participant towards the end of the interview. They were asked to select one of the photographs that had meaning for them in relation to being a mother or a father and then describe the meaning the photo had for them.
This change in approach helped participants to talk more freely, and with greater depth, about a range of issues close to their hearts. Some of the identified risk factors were brought up in discussion by participants. For example, one of the participants chose ‘it’s a girl’ photograph and went on to describe how preference for a male child in Indian society is a major issue. This participant also raised issues such as female foeticide, female infanticide and the effect of gender preference on women, which may not have been discussed if photo elicitation was not used. She stated: ‘I don’t know what happened, whether that kid was not taken care of after she was born … they used to give birth at home. Either was that the reason why she did not survive, or it was purposely done to her, so she doesn’t survive….’ (participant 11).
This woman then continued in the interview saying: ‘and then I am a first born, and my grandfather was very upset when a girl child was born. And my mum narrates that to me that when I was born, he did not even come to the hospital.’ (participant 11).
The change in approach from participant photographs to researcher-generated photographs altered the type of information gathered. Participant photographs generated data related to familial and social aspects of pregnancy and the postnatal period in India. The discussions of these photographs were important to the participants but did not elicit information on wider societal issues. On the other hand, researcher-generated photographs initiated discussions regarding more prevalent issues in the Indian community that may be a source of stress for many immigrant women, which may result in mental health issues. Therefore, use of photographs enabled exploration of sensitive topics. We examine this change further in the discussion.
Free Listing
Free listing is a data collection technique that is used to generate lists of items related to a cultural domain. In this approach, the participant is required to list all items or words/terms they can recall for a given category (Quinlan, 2005; Zambrana et al., 2018). Free listing helps in summarising a range of words used when describing a domain, concept or a category (Stausberg, 2011). The lists can then be analysed and can produce data on the vocabulary people use when referring to or conceptualising a complex concept, such as mental health (Stausberg, 2011).
List of words in English, Hindi and Malayalam related to perinatal mental health.
Generating the words and phrases was relatively straightforward. There was a delay in receiving responses from some of the CSG members and several reminders were sent. A couple of members made contact with the first author to get clarification on what was expected from them. Some of the reference group members gave the words in both languages. This free list of words was used for pile sorting during interviews.
Pile Sorting
Pile sorting is a powerful method that can be used in the research of concepts, values, fears and constructs (Trotter & Potter, 1993). While using pile/card sorting, the participants are asked to divide a set of objects that are related to each other into piles or groups on the basis of ‘similarity,’ ‘relatedness’ or ‘co-occurrence’ (Rosenberg & Park Kim, 1975, p. 489).
Even though pile sorting is used primarily in quantitative research, it was used in this study as a qualitative method to obtain an insight into the words and phrases participants associated with mental health and/or illness. Participants were asked to sort the ‘free list’ of words obtained from the free list generation process, according to their concept or perception. For example, they were invited to sort these words or terms into the most common words used by their family and friends when referring to mental health and mental illness. The participants were also asked to describe the meanings of the piles they have sorted, similar to the approach used by Quintiliani et al., 2008. In the first few interviews, participants were also asked to contribute to the list of words they would use in addition to those offered; however, none of the participants suggested any words or phrases to add to the existing pile, so the participants in the later interviews were not asked to contribute words or phrases about mental health and mental illness.
In the first few interviews the participants were given the free list of terms and phrases and were asked to sort these into two piles. Most of the participants found this method easy to understand. However, they did not tend to elaborate on why they had placed certain words in a particular pile, and some differences were observed in the understanding and sorting of the phrases. For example, with one couple the phrase ‘worrying about newborn’ was sorted into the mental health pile by the woman and in the mental illness pile by the man. As no further explanation was sought by the researcher, an opportunity to initiate conversation about this was missed. In reviewing the lists following these interviews, it was decided it would be more productive to ask participants to sort or order the terms in each group. For ease of use, two copies of the same cards were made and given simultaneously to each partner (in couple interviews) to prevent influencing the other partner. The cards were also shuffled well before handing them to the participants.
As the data collection progressed, some changes were made to the technique and the way in which the free list of words was presented, and more detailed instructions were given to the participants, as mentioned above. Hence, in the subsequent interviews after sorting the words, the participants were asked to order these words by selecting the word they most closely associated with mental health first, second and so on, and then using this same process for mental illness. Participants were then asked to give a short comment on the reason for their selection of words.
Some interesting differences were observed as a result of this change in strategy. The word ‘exhaustion’ in one couple, for example, was sorted in the mental illness pile by the woman and into the mental health pile by the man. On further exploration, he explained it is normal and understandable that the woman feels exhausted in the postnatal period, as she is looking after herself, newborn and the family and also experiences a lack of sleep. Indeed, this was a useful discussion point in itself.
Asking participants to comment on their choice of phrases gave a better understanding of why they chose the phrase. As in the above example, another couple sorted ‘worrying about newborn’ into different piles. On exploring further, the mother said concern or worry about a baby is positive for a mother: ‘if I worry about something, about baby for example, if he cries a lot, I will take other steps or alternate steps, I will think what else? What do I do so he is more relaxed? That is why I think it belongs to mental health.’ (participant 5).
Use of free list of words assisted the participants in thinking more about the issue of mental health and mental illness. As one participant stated, ‘sharing thoughts with loved ones’ was an important aspect of mental health.
This change in approach to pile sorting proved to be valuable in gathering rich and varied data. Thinking about topics as they are presented and talking about them may be difficult for some people. However, with the change in approach, when sorting the pile, the participants got a chance to think about their reply and appeared to be more in control of the process. By explaining why the participants chose the phrases, more insight was gained into their constructions of mental health and interesting differences were evident in the explanations provided by them. It gave a clearer picture of the terminology used in terms of mental health by Indian immigrants.
Integration in Mixed Methods Research
As this study is a mixed method study, researchers aim to integrate and mix methods of data collection and analysis with an aim to ‘combining for completion’ (Bazeley & Kemp, 2012). As described by Bazeley and Kemp, integration would be purposeful where ‘each piece will contribute to the total’ such as in ‘mosaic or a jigsaw’ (Bazeley & Kemp, 2012, p. 59).
During the data collection phase, as explained earlier, in-depth interviewing was used prior to introducing photo elicitation and pile sorting. The data collected from each method will be scrutinised and cross referenced with other methods, which will lead to a better understanding of the constructions of mental health in Indian immigrants.
Discussion and Reflection
In-depth interviewing is prominently used in qualitative research and is a very effective method for generating qualitative data. However, interviews may fail to elicit in-depth information, especially when sensitive topics are involved. Mental health and mental illness are examples of such sensitive topics, which constitute a need to explore other methods to initiate dialogue involving sensitive topics.
In order to inform the best approach to initiate a dialogue about mental health among pregnant women from diverse cultural backgrounds in our study, a range of methods were used in conjunction with in-depth interviewing. The use of multiple methods aimed to obtain data that would contribute to the understanding of how the concept of mental wellbeing and illness was constructed by Indian immigrants. As the research progressed, certain challenges were faced and changes in the use of photographs and pile sorting had to be considered.
Photo-Elicitation
In this study, there were some challenges in using photographs effectively. Participant-generated photographs provided a sense of familiarity and comfort to the participants, as contended by Collier (Collier & Collier, 1986); but this approach did not appear to elicit rich data related to the research. This may be because in this approach, the researcher became the ‘audience’ for the woman’s or couple’s narrative. Therefore, researcher-generated photographs were utilised for the remaining interviews to ensure that the participants were the ‘audience’, and it was the participants’ responses that were being elicited, not the reverse. There were also other significant benefits of using researcher-generated photographs, namely, they gave consistency of stimuli to all participants and consistency during analysis. Using the same photographs for each participant provided depth to the discussion within a single contact and facilitated exploration of social issues. As Harper (2012) suggests, regardless of the source and purpose of the photographs (participant- or researcher-generated), understanding the meaning of the image by working together with the participants is a ‘dynamic and exciting proposition’.
Bates states the use of photographs may introduce new dimensions to explore in the research (Bates et al., 2017). For example, in reviewing the literature, gender preference of a male child in India was identified as a stress factor in women of Indian origin, but there was no direct question related to this issue in the semi-structured interview. As mentioned earlier, the photograph, ‘it’s a girl’ provoked a strong response in one participant. Not only did this photo steer the discussion towards a social issue common across different religious groups in Indian society (Gupta, 2003; Thomas & Mishra, 2012), but it also stimulated the memory of this participant and resulted in a rich discussion about this topic. Use of photographs in this study helped break down barriers, which prompted in-depth discussion on the sensitive topic of gender preference and the resultant stress on women during pregnancy and the postnatal period.
Similar findings have been illustrated in other studies using photo elicitation where discussions by participants led in directions that the researcher did not anticipate, if they had used interview on its own (Notermans & Kommers, 2013; Williams & Whitehouse, 2015). When Notermans and Kommers (2013) used culturally significant images in their study, they were able to engage the participants in conversations that gave additional meaning to social and cultural artefacts. Use of researcher-generated photographs with in-depth interviews was very valuable, as photographs were tangible items that helped participants in focussing their attention. These photographs facilitated the development of rich descriptions and encouraged interviewees to organise their thoughts in a manner that was meaningful, both to them and the researchers.
The photographs used for photo elicitation were either provided by participants or were selected by the researchers. Participants were not asked to take photographs for the purpose of the interview, as has been seen in some other research (Copes et al., 2018; Gorm & Shklovski, 2017). Participant-driven or generated photographs could have given more insight into the immigrants’ constructions of perinatal mental health and mental illness. One of the advantages of participant-driven or generated photographs is that it can be an empowering experience for the participants (Church & Quilter, 2021; Marsh, 2016). Pairing of both participant-generated and researcher-generated photographs could also have been beneficial in this study. Some images such as ‘It’s a girl’, may have provoked conversations that would not otherwise have arisen, and to have used non-descript images would not have achieved the goal of promoting difficult conversations.
Free Listing and Pile Sorting
The decision to use free listing of words and pile sorting was made to identify terminology used by Indian immigrants when discussing the concept of mental health and mental illness. Some practical challenges were faced during initial interviews regarding pile sorting. The tasks of classifying, ordering and describing the order were added to the sorting task as the interviews progressed. These changes in the technique (of discussing their selection of words) gave some insight into how Indian immigrants associated certain terminology with mental health and mental illness that was not elicited by sorting alone.
Another challenge that was faced was the precision of recording the data during and after the participants sorted and ordered the piles. This was addressed by maintaining a detailed written record of the pile sort of each participant, in addition to audiotaping the interview to capture participants’ decisions, choices and rationales in real time. To help with ease of recording, a record sheet was maintained, and the cards were retained in the order the participants gave, which was further verified with the record sheet. Similar challenges were faced by Neufeld, who used card sort in a study of women’s evaluation of non-support and family caregiving (Neufeld et al., 2004). Neufeld also came across some procedural and practical issues. They used three different pile sorting approaches to engage participants. Similar to this study, Neufeld also asked the participants for rationales of their choices, which generated detailed information.
Comparable to the observations made by Sutton in her study to elicit women’s embodied experiences in Argentina, one of the challenges was that the themes did not emerge in an orderly fashion as they would have in a study aided by questionnaires (Sutton, 2011). Similarly, in this study, when the participants started narrating the thoughts that arose from ordering and classifying the cards, the conversation covered a range of topics. Close observation, careful listening, note taking and recording the preferences of each participant helped overcome this challenge to some extent.
Pile sorting generated rich qualitative data. In the initial interviews, participants were asked to contribute to the list of words and phrases they thought would relate to mental health and mental illness in the Indian context. In later interviews, as none of these participants contributed to the list, participants were not asked to add new words or phrases. It is possible that if we asked the later participants to contribute new lists and words, a more varied set of words may have been added.
By using further explanations to describe their preferences, participants were able to reflect on why these terms were important in the Indian context. For example, the terms ‘black magic’ or ‘possessed’ as described by the participants are still thought to be associated with mental illness in some parts of India. The pile sorting method proved to be more sensitive in generating information about the study topic, similar to Lugina et al. (2004), who found that the respondents had more control over the procedure and provided more valid information when using card sorting. The factors that contributed to the success of free listing and pile sorting methods in our study were inclusion of people from different walks of life in the reference group, changes in the approaches to various techniques used and the sensitivity of the interviewer.
Limitations
Use of multiple methods in this study had some limitations. Ideally, this study could have been developed in a sequential or longitudinal manner, where the research team engaged with participants over time. If knowing what images or words would have been beneficial in understanding the constructions of mental health was the purpose of this study, then these methods should have been undertaken sequentially. But, as the intention was to find methods that could stimulate participants to think about and discuss issues or topics that are rarely discussed, such as mental health and mental illness, the decision to use a range of methods in one interview was appropriate. A strength of the study was that the pile sorting was undertaken on a list of words that had previously been empirically generated with the CSG. Photo elicitation and pile sorting both served to enrich the one-to-one interview, which was the primary source of data collection for this study.
Conclusion
In conclusion, the use of multiple methods as an adjunct to in-depth interviews has enhanced the depth of data in this study. With the use of photographs, participants were able to express themselves and tell their stories related to the sensitive issues being explored. With the use of a free list of words and their sorting, detailed narratives of the meanings of the words emerged. Participants were able to offer their own understanding of the words and elucidate how, in the Indian context, these words gave meaning to the concept of mental health and illness. Hence, use of multiple methods for data collection in the qualitative phase of a research, especially with participants from non-English speaking background, proved to be very effective.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
Human Research Ethics Committee approval was received in July 2018: Study number H12784. Subsequently an amendment form request was submitted and approved in March 2020.
