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Visual Elicitation

Methods for Enhancing the Quality and Depth of Interview Data in Applied Qualitative Health Research

Orr, Elizabeth R. MSc; Ballantyne, Marilyn PhD; Gonzalez, Andrea PhD; Jack, Susan M. PhD

Author Information
doi: 10.1097/ANS.0000000000000321
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Abstract

RECOGNIZING the complex nature of health and health systems has led many practitioners and decision makers to use qualitative research evidence to inform and guide their work.1 Qualitative research evidence is used to direct clinical or policy decisions; to inform program evaluations; to theoretically develop new interventions or assessment tools; to understand client or community experiences—leading to more empathetic care; to stimulate new ideas; or to validate positions, programs, and services.2 However, the usefulness of qualitative research evidence in many ways rests on a researcher's ability to generate high-quality or rigorous findings, with the quality of such findings depending largely on the generation of data that are rich in detail and lead to a deeper understanding of the phenomenon of interest.3

The interview is one of the most common ways of eliciting information or coproducing knowledge in the health, human, and social sciences,4 and semistructured or in-depth interviews are ubiquitous within qualitative health research methods. In-depth interviewing (a) seeks deep information and understanding (eg, a way to learn the meanings of participant's actions); (b) relies on open-ended questions; (c) goes beyond common sense explanations or understandings of events, activities, or places; and (d) generates deep understandings—allowing researchers to grasp and articulate multiple views, perspectives, and meanings.5,6 Researchers use semistructured or in-depth interviews to study topics about which the participant has had substantial experience. The interviews are usually organized around a set of predetermined open-ended questions and during the interview, the participant talks while the researcher encourages, listens, and learns.6,7 Interviewing may be perceived as a rather simple form of data generation—merely a conversation between 2 individuals. However, the depth and detail required in the data to produce meaningful results and the skill required to generate this rich qualitative data are often underestimated and can often be difficult to operationalize. The use of visual data elicitation tools and techniques, a form of arts-based research methods, in conjunction with more traditional semistructured or in-depth interview techniques can mitigate some of the threats to generating rich qualitative data.

The aim of this methods-focused article is to (a) discuss the value of incorporating visual elicitation tools with semistructured or in-depth qualitative interviews to enhance the richness and depth of data generated and (b) provide a specific example of how this is planned and executed within the context of an applied health research study.

Statements of Significance

What is known or assumed to be true about this topic:

  • The usefulness of qualitative research evidence often rests on a researcher's ability to generate high-quality or rigorous findings, with the quality of such findings depending largely on the generation of high-quality data.
  • The interview is one of the most common ways of eliciting information or coproducing knowledge in the health, human, and social sciences; however, despite the perceived simplicity of the interview—from a technical standpoint—the quality and depth of data required to produce meaningful results can often be difficult to operationalize.

What this article adds:

  • Common threats to the generation of high-quality data from semistructured or in-depth interviews including establishing rapport, power imbalances, and participant factors are discussed with visual elicitation strategies described to mitigate these threats.
  • Considerations and planning required for incorporating visual elicitation tools to enhance semistructured or in-depth interviews are outlined using an applied health research example.

ARTS-BASED METHODS AND QUALITATIVE INTERVIEWS—A BRIEF OVERVIEW

Arts-based research is an umbrella term and can be defined as “research that uses the arts, in the broadest sense, to explore, understand, represent and even challenge human action and experience.”8 Arts-based research methods “are a set of methodological tools used by researchers across the disciplines, during all phases of social research, including data generation, analysis, interpretation and representation.”9 In health research, arts-based methods are for the most part used in combination with other data collection strategies, particularly questionnaires and interviews, and include visual, literary, and performance-based strategies.10

Within qualitative health research, visual arts-based methods such as photography, drawing, digital storytelling, animation, and collage are the most commonly used strategies.10,11 Photovoice, for example, is a process of study participants using photography to identify, represent, and enhance their community through creating and discussing photographs.12 This visual arts-based method has also been extended and modified in the age of social media using popular photograph-sharing applications data generation.13 Poetry is an example of a literary arts-based method that uses repetition, rhythm, and rhyme to allow the reader to see and hear the data across new dimensions.11 Found poetry is a specific example where a poem is created by taking words, phrases, or whole passages from other sources such as interview transcripts and reframing them as poetry.14 This method was used by Reilly and colleagues14 to distill the findings of a study examining how art-making shaped the trajectories of women diagnosed and treated for breast cancer. Theater, dance, music, and performance poetry are variations of performance-based methods within arts-based research.10 Research-based theater has been adopted across a wide variety of academic disciplines including health research and has the potential to engage researchers and audiences in both critical and empathic explorations of health and illness within a live space.15 For example, Mitchell et al16 describe the process of creating a research-based drama about living with dementia. The resulting performance piece presents understanding gained from a decade-long program of research and connects it with persons who might benefit most from the research findings.

Most often, health researchers cite limitations of traditional qualitative data collection strategies in communicating the subjective human health experience and the need for alternative methods as rationale for adopting arts-based strategies.17 In the context of the qualitative interview, arts-based research methods are often employed as a strategy to elicit contributions from interviewees that are difficult to achieve by verbal exchanges alone.18 The most common elicitation tools are photographs, but other visual tools are increasingly being utilized and include drawings, maps, and other visual artifacts.

VISUAL ELICITATION TO MITIGATE THREATS TO GENERATING DEEP AND DETAILED INTERVIEW DATA

Qualitative health research is a unique subdiscipline of qualitative inquiry; differentiated from traditional qualitative research by its focus on the health-illness continuum and methods employed to accurately capture these phenomenon of interest.19 Researchers operating within this unique context of qualitative health research are often forced to adapt the methods used in general qualitative inquiry to address factors specific to the health-illness focus of research, for example, limited time to conduct interviews due to pain or patient treatment schedules.19 Discovering and utilizing innovative ways to enhance the depth of data obtained from qualitative interviews and increase the overall rigor of a study, such as using visual elicitation tools, are examples of the strategic and purposeful selection and adaption of methods for a qualitative health research study.

Incorporating a visual task into a standard semistructured or in-depth interview can be very helpful for elicitation purposes, allowing participants to go beyond the verbal mode of thinking and connecting with wider dimensions of the experience of interest that may otherwise be disregarded.20 Visual tools or tasks used for the purpose of enhancing qualitative interviews include viewing and discussing photographs21; mapping exercises such as concept maps and mind maps,22 relational maps,20 and ecomaps23; creating time lines24; and other drawing activities25 (eg, patients with chronic obstructive pulmonary disease draw their lungs26).

Common threats to the generation of deep and detailed data from semistructured or in-depth interviews include establishing rapport—or the inability to do so7,27; power imbalance28,29; and participant factors impacting the ability to transform experiences into spoken word or narrative—including language and cognition.30–32 These threats may be mitigated by introducing visual elicitation methods to facilitate and enhance the traditional qualitative interview.

Establishing rapport

Developing rapport and engaging research participants in a conversation are central to generating data that are meaningful and useful; in-depth interviews must create an open and interactional space that develops and builds on intimacy and trust.5,6,27,33 Typically in qualitative health research, this rapport needs to happen rapidly, as the nature of the semistructured interview process does not allow for the development of trust or rapport over time (in contrast to traditional ethnographic research).7 Even the most skilled interviewer can encounter challenges in creating an environment where this kind of interaction can occur and additional considerations are often required when planning research among certain participant groups—including youth and marginalized individuals where rapport can be particularly challenging.31,34 Incorporating visual elicitation methods such as photographs and drawings can make a semistructured interview more intriguing for participants and ultimately less intimidating.35 These methods can be useful as a lead-in or icebreaker or can serve as a stimulus for the interviewer, resulting in further questioning and elaboration, thus allowing for an enhanced data generation experience and rich qualitative data.20,36

Power imbalance

The relationship between the researcher and the participant in qualitative research interviews is characterized by power imbalance—with the interviewer having the authority to frame the interview and ask the questions—in addition to the presence of potential imbalances involving gender, race/ethnicity, class, and education.29 This power imbalance can threaten the quality of the data generation as participants may employ “problematic interviewee behaviors” (eg, social desirability) or shift the focus of the conversation completely.28 Visual elicitation methods situate the research participant as the expert in the interview transaction and can facilitate increased participant authority in the research process—thus enhancing trust and overall engagement.35,36 These methods also allow the participant control over how their data are analyzed, for example, participants engaged in a drawing activity are subsequently asked by the researcher to describe and explain their depictions, thus avoiding de-contextualization of the drawing or misinterpretation by the researcher.37

Participant factors

Understanding the patient or client experience is central to qualitative health research in the questions posed and methods used—and this understanding can lead to genuinely empathic practices and policy. Certain groups, however, may be difficult to involve as participants in research, such as children and young people, people experiencing cognitive delay or decline, or the frail elderly—yet exclusion from research prevents these individuals, as well as the groups they represent, from the benefits of research participation.38 Visual elicitation tools can enable participation in data generation for a broader range of participants, including those for whom the ability to transform experiences into spoken word (or generate in-depth of detailed data by more traditional methods) may pose challenging.35 For example, Teachman and Gibson39 utilized cartoon captioning in a study exploring beliefs, assumptions, and experience of children and youth with disabilities. Participants were asked to fill in the speech bubbles above the heads of 2 characters in a cartoon provided by the researchers, eliciting perspectives that may have otherwise been missed with interview methods alone. Similarly, the use of visual aids or prompts while interviewing may facilitate the expression of feelings and greater depth of data generated among the frail elderly.32

Cognitive factors such as those associated with typical developmental stages can also contribute to challenges in generating rich data from interviews. For example, among adolescents the prefrontal cortex (the region of the brain responsible for advanced reasoning) is less developed compared with adults, which could lead to difficulty considering and articulating complex understandings that may be expected in a traditional qualitative interview.40,41 Visual elicitation methods have been utilized specifically among youth research participants to mitigate these challenges associated with this typical developmental stage.20,41 For example, researchers using a visual storytelling method cite the use of visual images and in-depth interviews as effective in promoting reflection and communication about issues that could otherwise be difficult for young participants to conceptualize or express in conversation alone.30

VISUAL ELICITATION TOOLS TO ENHANCE QUALITATIVE INTERVIEWS—CONSIDERATIONS FOR PLANNING AND EXECUTION

Developing a qualitative health research study plan or protocol requires careful planning and decision making around choosing a topic, selecting as design, writing a research question, and choosing methods that facilitate the research aims (eg, describe a health- or illness-related phenomenon).42 Data generation methods need to allow for the expression of a participant's thoughts, values, and beliefs in order to understand how an individual or a group experiences the phenomenon of interest—making the interview a method of choice.42 Anticipating threats to data generation from semistructured or in-depth interviews and planning strategies—such as visual elicitation tools—to mitigate these threats can save a researcher's valuable time and resources while also maintaining the responsibility for high-quality research processes and outputs. In this section, we describe the considerations and planning required (Table 1) for incorporating visual elicitation tools to enhance semistructured or in-depth interviews using an applied health research's example (see Table 2 for brief study context). This example is based on a study titled “NICU-to-Home Transitions Study—Understanding the Transition Experiences of Adolescent Mothers With Newborns Discharged Home From the Neonatal Intensive Care Unit (NICU).”

Table 1. - Visual Elicitation in Qualitative Interviews—Considerations and Planning
Purpose Identify the purpose of incorporating visual elicitation tasks or tools into the interview. For example, to facilitate rapport among a difficult-to-engage participant group.
Tool/Technique Selection Select the visual elicitation tool(s) or strategy(ies) that will contribute to answering the overarching research question. For example, relational mapping to capture the relational networks of study participants.
Elicitation Guide Integrate the visual elicitation tool or strategy into the interview guide. For example, outline the activity for the participant as well as prompts to facilitate the subsequent discussion.
Analysis Choose an analytic strategy that is congruent with the overall research objectives and design. For example, throughout the interview, allow the participant to analyze his or her depictions for the researcher to avoid decontextualization and misinterpretation.
Data Representation and Dissemination Consider how visual data may be used in the representation and dissemination of research findings. For example, individual time lines analyzed and synthesized into a meta–time line or journey map.
Ethical Considerations Consider the additional ethical safeguards required when using visual elicitation in the research process. For example, establish expectations regarding ownership of participant-produced visual outputs.

Table 2. - Brief Study Context and Purpose—NICU-to-Home Transitions Study
Example study: NICU-to-Home Transitions Study—Understanding the Transition Experiences of Adolescent Mothers With Newborns Discharged Home From the Neonatal Intensive Care Unit (NICU)
Background/context: Pregnant and parenting young women often experience high levels of social and economic disadvantage including difficulty accessing critical health and social care services—leaving them and their infants vulnerable to poor outcomes.43,44 Infants born to adolescent women are also more likely to require hospitalization in a NICU shortly after birth.44–46 An extended NICU stay can disrupt maternal-infant attachment and decrease breastfeeding rates and postpartum engagement with community-based health promotion and early intervention services, therefore, increasing the vulnerability of this already complex mother-infant dyad. The unique social, psychological, and developmental context of the adolescent mother combined with the complexity associated with NICU-to-home care transitions underscores the need for an age-specific understanding of their experience and supportive care needs postdischarge. Currently, however, very little is known about specific experiences of Canadian adolescent mothers when they transition home from NICU.
Purpose: To develop a midrange substantive theory to explain how adolescent mothers experience transition to home and community following discharge of their infant from the NICU.
Abbreviation: NICU, neonatal intensive care unit.

  1. Purpose: The purpose of incorporating visual elicitation tools into the data generation methods of a study can be linked to the anticipated threats to the generation of deep and detailed qualitative data, for example, establishing rapport. In the NICU-to-Home study, the population of interest was adolescent mothers making the transition from hospital to home after their infant's stay in a neonatal intensive care unit. Many adolescent mothers have experienced negative health care encounters that have contributed to disengagement and mistrust of the health care system and health providers.47 As a research team consisting of nurses and other health professionals seeking to engage young mothers in conversation about their health experiences in the NICU, we needed to consider strategies that would reduce perceptions of stigma and power imbalance on behalf of the participants, thus facilitating rapport during the research interview. This served as our purpose for considering visual elicitation tools during the individual semistructured interviews.
  2. Tool or Technique Selection: Once the purpose has been identified, researchers can now consider the type of visual elicitation tool or technique that will serve this purpose and contribute to answering the overarching research question. Various visual art forms can be used for elicitation purposes during semistructured interviews with the most common in health research being photographs, videos, and drawings.11,17 In the NICU-to-Home study, drawing—specifically time lines and relational maps, were the techniques selected. Time lines are a visual depiction of significant life events displayed in chronological order that facilitate recollection and sequencing of personal events and help capture temporal dimensions of studied concepts.20,36Relational maps are an elicitation tool where participants are asked to draw themselves and important people in their lives using distance from oneself to represent importance (with importance diminishing as distance from oneself increases).20,37
  3. Relational maps and time lines were chosen as they may be less threatening than direct dialogue with the researcher and offer a technique to approach sensitive or personal topics.20,25,35 These methods can also be effective at reducing researcher-participant power differentials, an important consideration when interviewing adolescents as they can be easily intimidated and feel dehumanized in the research process as an object of knowledge.35,48 Visual methods can also capitalize on a stage of heightened creativity in adolescence, allowing for unique opportunities for validation of youth participant narratives.49,50 These particular visual methods also contribute to the overarching research question of the NICU-to-Home study. Relational maps and time lines allow for important relationships and significant time points in a young mother's life as she transitions from hospital to home with her newborn to be captured, analyzed and ultimately understood by the research team.
  4. Elicitation Guide: A clear description of the visual elicitation technique as well as appropriate prompts to guide the subsequent discussion will allow for a smooth integration of these tools into more traditional interview processes. Similar to a semistructured interview guide that lists a number of open-ended questions with flexibility to probe for deeper exploration,42 the elicitation guide will lead the participant through the drawing activity and provide areas for the interviewer to question and probe. An elicitation guide for both the time line and the relational map drawing activities was created by the research team for the NICU-to-Home study (see Table 3 for sample relational map elicitation guide). Note that the interviewer provides very little scaffolding for the activity to the participants, therefore, allowing them to construct their own representations and allowing for a discussion between the interviewer and the participant about what was included and why.
  5. Analysis: As visual elicitation strategies are primarily for the purpose of facilitating communication between the researcher and the participant, analysis is often conducted within the context of the interview by asking participants to describe and explain their depictions. This is important to avoid de-contextualization of the drawing or misinterpretation by the researcher.37 The subsequent discussion is then analyzed as text according to the study's analytic design (eg, qualitative description, reflexive thematic analysis, grounded theory). Additional analysis of the visual data itself can also be completed with content and thematic analyses commonly used in health research using visual methods.17
  6. In the example study, participant interviews were recorded and transcribed verbatim thus capturing the discussion of the relational maps and time lines and the elicitation of deep and detailed descriptions of the transition experience. These in-depth interviews—enhanced with the elicitation strategies of time lines and relational maps—are then analyzed as text, much the same as a traditional in-depth interviews, according to constructivist-grounded theory methodology and the processes outlined by Charmaz6 consisting of initial coding, focused coding, theoretical coding, and memo writing. While elicitation of rich data is the primary purpose of the drawing activities, the creation and discussion of the maps and time lines can facilitate certain analytic strategies. For example, temporal ordering is a coding strategy used in grounded theory analysis to understand the processual nature of a phenomenon6; therefore, the inclusion of the time line activity allows the participant to begin this temporal ordering within the context of the interview and the researcher to continue this analysis by comparting across participants and incorporating this ordering into the overall analysis. The maps and time lines also lend themselves well to constant comparative analysis—a strategy central to grounded theory analysis—where individual maps and time lines can be lined up and compared incident to incident and scrutinized for variation in processes and relationships. These visual outputs from the interviews may also serve as starting points for the maps, figures, charts, and other visual representations produced while teasing out relationships, processes, and ultimately how the resulting ground theory fits together.6
  7. Data Representation and Dissemination: While the purpose of the elicitation tool may be primarily to facilitate the generation of rich interview data, researchers should consider the power of visual data when representing and disseminating the findings (see Figures 1 and 2). Visual methods are powerful Knowledge Translation (KT) tools. Visual representations of research evidence (eg, images, art, videos) are largely accessible and therefore facilitate dissemination across broad audiences.35 Visual outputs have the power to impart knowledge by attracting interest and developing meaningful connections with research findings and therefore hold strong potential for effecting change among knowledge users outside of academic institutions.35,51 For example, time lines outlining the many individual transition experiences of adolescent mothers can be analyzed, synthesized, and represented as a meta–time line or journey map52 that communicates salient and systemic issues within the health and social systems these young mothers navigate.
  8. Ethical Considerations: Additional safeguards to protect participants will need to be considered when using visual elicitation methods during qualitative interviews. Fundamental ethical values when conducting research with human participants still guide this consideration; however, how the visual tools may influence these values requires careful reflection.35 Photographs and the other visual depictions may identify participants or their environments, thus compromising confidentiality. In the example study, strategies to ensure confidentiality include anonymizing digital images by removing or blurring identifiers (see Figures 1 and 2 for example de-identification). Ownership of visual outputs must also be considersed.35 In the example study, the participant is considered the owner of their visual depictions with the research team asking for permission to obtain a digital copy for analysis. Visual methods are also often used to facilitate expression of emotions and tacit knowledge, as such researchers need to safeguard the participant by minimizing potential risks, promoting transparency during the consent process, ensuring ongoing consent throughout the interview process, and ensuring that a protocol is in place for assessing and addressing emotional distress.35,53 To minimize the risk of negative emotional impact as a result of participation in the example study, the research team developed a detailed distress protocol and ensured ongoing consent by asking “okay to continue” at multiple points throughout the interview process.
Figure 1
Figure 1:
Example time line from NICU-to-Home study. NICU indicates neonatal intensive care unit. This figure is available in color online (www.advancesinnursingscience.com).
Figure 2
Figure 2:
Example relational map from NICU-to-Home Study. This figure is available in color online (www.advancesinnursingscience.com).
Table 3. - Sample Interview Guide Using Relational Map Graphic Elicitation Method
Introduction
Interviewer:
Thank you for taking the time to be interviewed today.
Some people find it helpful to use drawings to tell their story, so during our time together we're going create some drawings to help highlight important parts of your transition-home experience.
Relational Map Activity
Before the drawing begins
  • Provide printed relational map instructions to mother.

  • Explain that the purpose of the relational map is to place important people in a picture around themselves with those closest relationships drawn near and those not as close drawn further away—similar to the solar system with the mother being the sun and the people in their life being planets different distances away.

  • Emphasize that individuals complete this task differently and that there is no right or wrong way to draw their relational map.

Relational map activity instructions

In this activity, we are asking mothers to draw a relational map.

In other words, draw a picture of you in the center of the page, and then show the important people in your life by drawing them on the paper. Draw the people most important or closest to you in the space near you in the picture, and those less important or not as close further away in the picture. Different people draw this in different ways, and there's no right or wrong way to draw your relational map.

  • Things you might want to consider for your relational map:

    Include important people such as family, friends, care providers (doctors, nurses, social workers), teachers, and role models.

  • Maps could also include people you wish were in your life.

  • Important people or relationships do not have to be “good” or “positive” to be important in your life—for example, bad relationships can still be considered important.


You can describe what you are doing while you draw or complete the drawing without talking. After about 10 minutes, I will ask you to tell me about the map you drew.
Participant draws map—after 10-15 min, ask the participant to describe what he or she drew.
Potential probes for elaboration during discussion of relational map
  • PROBE—Looking at the map.

    • What makes a relationship more or less important to you?

    • What makes each of these people important to you?

    • Is there anyone that you wish were closer to you in this map that is currently further away? Why?

    • Are any of these relationships particularly difficult? Rewarding? Why?

  • PROBE—How have your relationships changed since before learning you were pregnant and now?

  • PROBE—What (if any) care providers (doctors, nurses, social workers ...) have you placed on your map?

    • How have these relationships changed over time?

  • PROBE—Has anyone been with you on the entire journey since before learning you were pregnant until now?

  • ASK—Is there anything else that you would like to tell me about your relational map that you think is important for me understanding your story?

Concluding the relational map activity
Interviewer:
Thank you for sharing your relational map with me. Do I have your permission to take a picture of this map and we will revisit it when we meet again? I may also use examples of drawings when I write about and/or present my study findings, may I use your drawing in this way? All personal details will be removed or replaced with “fake” names and places.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Integration of visual elicitation tools and techniques into qualitative interview methods by nursing and other applied health researchers can improve the depth and detail and overall richness of their interview data. This can be particularly important when conducting qualitative interviews on sensitive topics or with participants experiencing vulnerability or marginalization as is often the case in nursing research. Qualitative data that are rich in detail and lead to a deeper understanding of the phenomenon of interest can produce more rigorous qualitative research evidence that can then be used in many ways that are important to nursing practice, including informing clinical or policy decisions, understanding client experiences, and stimulating new ideas or validating positions, programs, and services.2 Visual methods should also be considered by nurse researchers for the dissemination of research findings as a method that is accessible to knowledge users, thus strengthening the potential impact of research evidence.

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Keywords:

arts-based methods; data collection; qualitative interviews; qualitative methods; qualitative research; visual data

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