During ethnographic fieldwork a researcher works alongside participants to try to understand experiences and knowledge within a particular context. Ethnographers often spend long periods of time conducting fieldwork in order to achieve an insiders’ perspective. However, achieving this takes time and is not necessarily straightforward. Part of the process of fieldwork depends on ethnographers reflecting on their own position and the relationships they build with participants. This article focuses on some of the challenges I encountered of working within a new context, including personal interaction and mutual understanding of roles. It is hoped that future researchers will be encouraged to consider the impact of their own positionality on findings.
Ethnography is a research methodology that aims to understand cultures, organisations and communities and from the perspective of its members. Data collection involves immersing oneself in a community or social system for an extended period of time and this method generates insight into complex settings. A range of methods can be used which include observation, interviews and documentary analysis. Priority is often given to exploring the meaning and intentions behind participants’ actions. Ethnographers are often interpretivists, researchers who emphasise the role of the researcher in shaping data collection and analysis. In addition, they acknowledge that how participants’ relate to researchers may also shape the kinds of data they collect. Ethnographers are encouraged to reflect on these issues by keeping a fieldwork diary, documents that record their relationship with the communities under study.
Around 800 children are thought to be born with idiopathic clubfoot annually in Malawi[5, 6]. Clubfoot is a congenital condition in which one or both feet are twisted inwards. It is not initially painful but if untreated, clubfoot can impair function including mobility, limit participation in everyday life and result in ostracism from the community. Clubfoot can be treated by stretching and manipulating the affected leg or legs with plaster of paris, a treatment called the Ponseti method. The method has been adopted by the Malawi National Clubfoot Programme (MNCP) as the national standard and treatment delivered by the Beit CURE International Hospital in Blantyre which also coordinates 26 outreach clinics. Clinics operate in District Hospitals throughout Malawi. However, implementing these services is complex; a high proportion of children with clubfoot fail to present; adherence to treatment is low; and treatment is often delayed .
This ethnographic study aimed to use qualitative research methods to: a) Explore the implementation of clubfoot services including how they are organised, structured and delivered; b) examine the experiences of children and their guardians of accessing and utilising the services; c) examine the experiences of those that have ceased to access services. It is hoped that this information can be used by the hospital to help develop services to better meet the needs of patients. Funding was provided by Cure International UK.
As part of the study I undertook formal semi-structured interviews, focus groups and informal interviews and observations with guardians that had accessed clubfoot treatment at one of the CURE Hospital outreach clinics. Data collection largely took place in participants’ home villages that were located in the Southern Region of Malawi. To assist with data collection and analysis, I worked with a local Research Assistant from Beit Cure Hospital who provided language translation and interpretation of data. In this article I aim to present personal reflections on my experiences of interpreting a new context and participants’ perceptions, based on excerpts from the diary I kept during fieldwork.
Interpreting a new context
My difficulties in navigating an unfamiliar context had implications on ethical conduct, processes of data collection and analysis. For instance, throughout data collection I had become aware that it was not normal for people in Malawi to say an outright “no” to doing something when asked, something that raised difficult questions about the notion of informed consent. I was also aware it very difficult for me to ‘read’ the body language of participants during interviews. Were they uncomfortable with the line of questioning? Should I interpret their silences as distress and move on to another topic, or shyness, in which case should I probe deeper? In one case, I came away from an interview mortified that I had upset a couple who had been very reticent to speak throughout the interview only for my Research Assistant to inform me that he thought they were going through a crisis at home: “they need marital counselling, not an interview on clubfoot”.
Most notably, a lack of understanding of the social context impacted on my ability to analyse data and understand the lives of participants, at least initially. During discussions with Paul, I was often dismayed by these failures. Halfway through data collection one of the young mothers we had followed longitudinally had married because, as her elder sister explained, “there was no food in this family”. I was pleasantly surprised when we met the newly married couple – the man was around her own age, the compound was respectable and he was teaching her how to sew, an activity that I assumed could provide her with a livelihood in the future. Paul was less optimistic: “in our culture it is an abomination to marry someone who already has a child. Which raises the question, why is he doing it? Maybe he is just enjoying the game. She is covering one problem [hunger] with another problem”. Sure enough, on a subsequent visit we found out that he was planning to move to South Africa without her the following year.
Relationships with participants
Participants attributed different identifies to me throughout the study based on their previous interactions with ‘outsiders’ of Western origin. I was often mistaken for a doctor or a representative from a donor organisation, no doubt encouraged by our association with Beit Cure Hospital. There was also concern about our motives, probably as a result of recent sensitisation campaigns around child trafficking. In one village, we were greeted by children singing a song in Yao about ‘the blood suckers’. This singing was based on worries amongst villages about people who broke into compounds and forced villagers to donate blood before the practice had been regulated.
Participants’ perceptions impacted on their responses to us. As a perceived representative of Cure, I was asked on a number of cases to intervene in their child’s care at the hospital. A family who had a child with clubfoot that had not received full treatment were struggling to re-enter treatment told us “while you are still visiting us, we have hope [for the treatment of the child]”. There were requests to assess other children and arrange transport for patients to the hospital. I was also asked to pay for the school fees of a young participant. On a memorable occasion I was led around the compound of a school by a head teacher and representatives from the community. It was only late into the discussion that I realised they thought I was there to build a school. To protect villagers from the malign influence of the ‘outsiders’, interviews were sometimes attended by the chief’s representatives who were able to monitor and report back on discussions.
Navigating these issues
I developed some strategies in order to try and understand experiences from the perspective of participants. Our Research Assistant became instrumental in helping me to understand the meanings and actions of participants and make decisions within the field. For instance, after data collection we compared our interpretation of situations and these discussions were recorded in field notes. I also developed creative ways of building rapport with participants to try and challenge their perceptions of me. I was excessively apologetic about not being able to speak local languages and tried to engage in activities such as pounding maize to try and have a little bit of fun and help put them at ease. My efforts to engage in and appropriate Malawian manners and dress also met with some success. An older lady told our Research Assistant he should be very proud of me, “she is a Yao, she is one of us. She has good manners, she can speak some of our language and sits on the mat without any trouble. No mini-skirts or trousers here!”. I was also secretly delighted when participants teasingly gave me the Chewa clan name “Anaphiri” meaning “from the mountains”.
This article explores some of the challenges I encountered conducting ethnographic fieldwork on clubfoot treatment services in Malawi. It shows that I found a fieldwork diary provided me with the chance to record and reflect on these challenges. I would highly recommend other ethnographers and qualitative researchers reflect on these issues in their own research.
1. Hammersley, M. and P. Atkinson, Ethnography : Principles in Practice. 2007, London: Routledge.
2. Rock, P., Symbolic interactionism and ethnography, in Handbook of ethnography, P. Atkinson, et al., Editors. 2001, Sage Publications Ltd: London, England.
3. Hovland, I., Fieldwork identities: introduction. Anthropology Matters 2009. 11(1).
4. Given, L., The SAGE Encyclopedia of Qualitative Research Methods. 2008.
5. Lavy, C.B.D., et al., Club foot treatment in Malawi - a public health approach. Disability And Rehabilitation, 2007. 29(11-12): p. 857-862.
6. Anna Cuthel, A.R.M., Cure Clubfoot Worldwide. 2009.
7. Alavi, Y., et al., Indignity, exclusion, pain and hunger: the impact of musculoskeletal impairments in the lives of children in Malawi. Disability And Rehabilitation, 2012. 34(20): p. 1736-1746.
8. IV, P., Congenital Clubfoot. Fundamentals of Treatment. 1966, Oxford: Oxford University Press.
9. Bedford, J., Perceptions of and treatment-seeking behaviour for Congenital Talipes Equinovarus (Clubfoot) Deformity in Malawi. 2009, Anthropologica
10. Bedford, K.J., et al., Clubfoot in Malawi: treatment-seeking behaviour. Tropical Doctor, 2011. 41(4): p. 211-4