Interview questions

I spent the morning writing my interview questions. John helped to type it up. Look at the nice format:

       

I chose to use a lot of questions from Brady, Verba and Schlozman's article (the one I discussed here). I want to ask the interviewees about their resources and civic skills in order to identify obstacles to participation, and since the questions by Brady et al. (Herafter BVS) were designed to do exactly that it makes sense to copy them; and this way the results can be cross-compared.

There are two major complications with importing BVS' questions. First of all, I am interviewing people in a mental health service, but a lot of the questions are not entirely relevant to their day-to-day life. For instance the question "Last week, were you working full time for pay, working part time for pay, keeping house, going to school, or something else?" can already be answered to some extent for probably all of the interviewees: they visited the service where I will be talking to them. In order to fix dis disparity I have added a couple more specific questions and slightly changed others - to the question in the example I added the option "visited the service".

The other complication is that this survey was designed for people in the United States, but this is Northern Ireland. The problem is not just that I have to edit the questions so that they apply to the local situation, so for instance "secondary school" instead of "high school". More importantly, because of the political situation in Northern Ireland people may feel scrupulous or hesitant to answer certain questions such as: what language do you speak at home? Are you a UK citizen? What is your religious denomination? I don't want to ask such questions unless strictly necessary. I added a disclaimer to let the interviewee know the research is not about the sectarian division and they do not have to tell me what side they are on.

BVS designed their questions for a large-scale quantitative interview. I am going to interview too few people to meaningfully compare my results, but still their results could serve as a way of placing mine in context. For instance, if a participant turns out to have very little time, we can refer to BVS who found that people with little time generally do not participate as much. The ease of integration of their questions in my interviews shows that a question is not inherently qualitative or quantitative; it depends on the number of research participants and on how the acquired information is processed.

P.S. I updated my consent form so that it is relevant to the actual questions. Here

The BMHRG suggests some very practical measures

(Note: I added a new page to the blog to explain the project I am writing these posts for)

I read the May 2012 report by the Belfast Mental Health Rights Group (BMHRG). They consist of service users and their carers and of families who have been bereaved through suicide, and they have ran a campaign for the past few years to try and improve first line care for mentally ill people in the Accident and Emergency room (A&E), specifically by lowering the time that people have to wait (4 hours just isn't acceptable if you are in a crisis) and by ensuring that people get a written notice of a follow-up appointment. In the report they explain how they have tried to monitor the progress on this campaign and in why they found it hard to. I wonder if A&E is really the best place for first line help as they are kind of notorious for making people wait for ages but to be fair the alternatives aren't as known or as accessible.

First of all I was very excited to read the following in their report as it confirms that my work so far has been on the right track:

Dr Helen Potts is a renowned expert in this area and she has previously
assisted the Belfast Mental Health Rights Group’s campaign for meaningful
and effective participation, her work and ours shows that participation requires
two things:
1.      Arrangements put in place to ensure participation at different stages
2.      Capacity building to ensure people have the ability to meaningfully and
effectively participate

We have been talking, on here, about capacity building; that's civic skill right there. However the arrangements at different levels are something that I still need to understand better; I think what it comes down to is that both the service user and the institution that needs to be influenced need to change things in order for participation to happen. The service user, with support from services (user-run or not) builds his capacity and in turn the institutions need to change their attitude to see the value and importance of involving users and carers and they need to put certain measures and agreements in place to make sure participation is meaningful, i.e. it is not just tokenism but users and carers have feasible influence and decision making power.

BMHRG go on to explain which practical measures they asked the Health and Local Care Board to take in order to allow the group to monitor progress and to know what was going on in the meeting. It is surprising how common sense some of these measures are, it seems like they are just requesting that common meeting etiquette is actually lived up to. This is their checklist (p.23/24 of the report):

Before the meeting:

• We had the date, time, location and agenda two weeks in advance.
• We had the opportunity to place items on the agenda and have them considered in a timely manner.

During the meeting:

• The language used was jargon free.
• Any information which was presented was in writing so we can discuss it with the rest of the group.

In general:

• Any disagreements were resolved at the meeting effectively.
• Our expenses were covered.

The list shows the challenges for any group of volunteers to participate: people have jobs/activities of their own so they need to be able to plan the meetings in advance and agree who attends them; they need to be able to discuss the meeting outcomes together and so they need to have the agenda and all the information from the meeting. The covered expenses makes sense if you know that a lot of service users rely on disability/jobseeker's benefits, but it also highlights that their participation should be valued by the Board. The Baoards's goal, after all, is or should be to offer a good standard of care; a goal which they cannot reach without input from those on the receiving end of the care.

The group sent the Board evidence that in over a year, these standards had not at all been lived up to. The Board have since given a staff member the task to ensure that they will in the future be lived up to; they have further said that they will use the lessons learned here in their wider participation projects, and that they would like to set up meetings so that this can be done. (p. 26)


Conclusions:

• The responsibility for making participation happen is on the side of the institutions as much as it is on the side of the service users
• Some of the measures that the institutions can take to ease participation are very practical in nature 

As for the attitude change; Liz Sayce and Barnes et al. (see previous post) all hinted that a lot of attitude change can be achieved by "just doing"; if a person who is open about their diagnosis finds a job, eventually people will realise that they can function normally and that they are not a constant threat (Sayce). For user groups the same goes: if a group calmly asserts themself and shows that they are well-organised and reliable, institutions will eventually come to accept this. In the case of the group studied by Barnes et al., the attitude change had been so far-reaching that by now, officials in the field feel it would be unacceptable for them to make a decision about local mental health planning without consulting the group first.

Building civic skill

In Friday's post on political exclusion I finished with a note about civic skills, a concept developed by Sidney Verba, Henry E. Brady and Kay Lehman Schlozman. I would like to expand a bit more on that concept in this post as it seems to me like this concept could be very useful in designing recommendations for encouraging participation in certain groups; they could receive training which focuses on building civic skills. Moreover I think that besides civic skill, confidence is an important factor in encouraging someone to participate.


1. What is civic skill and how do VBS measure it?

Civic skill is introduced in the article Beyond SES: A Resource Model of Political Participation, as one of the resources that people need to have in order to participate in politics. It is defined as "the communications and organizational skills that facilitate effective participation"(p. 271). Civic skills are developed through work experience, but also through being part of organisations (e.g. through volunteering for Humanitas), in high school government, and in one's church.

In their research the authors have used multiple indicators for civic skill, and they argue that these are perhaps not perfect but nevertheless do the job of indicating. They ask questions about:

• Level of education
• Participation in high school government (this one surprised me a little)
• Language proficiency
• Self-described skills and confidence
• "Skill acts"; how often did a participant attend a meeting where decisions are made, plan such a meeting, write a letter, or make a speech or presentation in the past six months a) at work b) for an organisation c) for a religious organisation (e.g. church).

2. Predictions about civic skills of mentally ill people based on known statistics of their employment, education etc

My hypothesis is that for mentally ill people, level of education and language proficiency will be roughly the same as for the rest of the population or slightly lower, but the real problem will be with the skill acts and the confidence. Note that these are related to each other: if a person writes a lot of letters he is more likely to feel confident in doing so (and vice versa.)

In this book I have here The Fundamental Facts 2007 from the Mental Health Foundation, they simply say that "low levels of education... are associated with a greater risk of experiencing a mental health problem" (p37). However, looking at the source they quote, I do not think this conclusion is merited. This (it links straight to the pdf) is the source they quote, a 2002 report by Her Majesty's Stationery Office. Table 2.1 on page 10 is about education level v. type of disorder. Looking at the column with all disorders grouped together and the one with respondents with no disorders, the differences can hardly be called significant: 28% of the people with disorders have no qualifications  versus 27% of the people without. 10% of both groups left school at 17. 39% of people with a psychotic disorder left school at 15, but then, there were only 60 such respondents.

This article however, "Education, sense of mastery, and mental health" is based on the premise that low education and mental health problems are linked - so there must be some truth to the claim. They refer to this source. I am now suitably convinced as they're psychiatrists and I'm not. The former article mentions that poor mental health may be one of the reasons why people have trouble completing their education. They advocate increased support and guidance for those who have educational problems.

It is a known fact that mentally ill people have more difficulty than average in getting and keeping a job. Sources: National Health Development Unit report, British Psychological Society (I am laughing at the line that they found "being a woman is the other strongest trigger influence on subjects with a genetic predisposition to mental disorder."). Also, an article from the American Psychological Association to say that unemployment also causes mental health problems. Relevant for our current topic is that if people are unemployed, they will have fewer opportunities for those skill acts that Brady, Verba and Schlozman talk about.

I do not have any statistics on organisation/church activity of mentally ill people, nor on their self-described skills (although I think that mental health problems often go hand in hand with low confidence and self-esteem, maybe because of the unemployment, the stigma attached to mental illness and the feeling of lack of control over one's own life.) I think it would be worth asking these sorts of questions if I get a chance to interview more people though; that said, anyone I'm going to be able to reach will already be a fairly active member of MindWise or NIAMH.


3. What would civic skills training look like? With help from M. Kirlin

For now I am interested in the question what sort of training could be offered to mentally ill people in order to help them improve their civic skill.  Let me advocate this a bit more: that civic skill is picked up largely on the work floor means it is also a job skill. Phoning people, writing letters, organising and participating in meanings; not far from the typical office job. Such training would need to be set up in such a way that it helps to build the self-confidence of the participants rather than patronise them (for instance with overly easy exercises). All in all it would work on several fronts at once; encouraging people to participate in politics and make their voice heard, preparing them for a job and helping to build their confidence at the same time.

For ideas on how to build civic skill I will borrow some ideas from Mary Kirlin, who in turn also got the idea from Schlozman, Verba and Brady's research. Her research focuses on adolescent "civic socialization" which I will remember as a key term that may become important later. By trying to apply her research to mentally ill people I am not trying to suggest that they are like adolescents, but rather that there is reason to expect that skill training that works in one place may also have positive effects for another group.

In this article she writes about community service programs and their influence on development of civic skills. She says she focuses on "how adolescents learn the doing of democracy, that is, active participation, not simply cognitive knowledge of political systems" (p.571). (Although seemingly straightforward, the distinction is a good warning for someone setting up a training programme). 


I think the most important conclusion in the article is that civic skill development happens when students are encouraged to organise themselves, to find out how to influence people and how to make collective decisions. This is why participation in high school government is almost unanimously found to be a good predictor of later political participation (she even claims with some conviction that this is not just due to self-selection of students who were already interested in politics), while sport clubs are negatively associated with later participation. Kirlin explains the latter:

While providing other benefits, organized sports provide little opportunity for civic skill development: the goal (winning) is predetermined, and adults undertake the planning for the season, organize the matches, and do most of the coaching. Opportunities for students to organise themselves, decide on objectives, and collectively make decisions are limited. The same may be increasingly true for service learning and community service: adults may have organized students too well, taking all the fun (and civic skill learning) out of the effort.  (p.573)

The point she makes here reminds me of something I read last November or so about mental health service users who organised themselves; initially they set up an emergency phone network for when staff wouldn't be available to call, so they could support one another; then that led to more and by now they have a walk-in service. I will try to find the source again tomorrow.

For now I would like to end today's post with a really cool thing from Kirlins's article - wish my university would offer this. In true Kirlin spirit I may go and suggest it to them.

I have begun testing this approach in an introductory undergraduate public affairs course. At the beginning of the term, students identify a public issue they would like to influence (by reading the local newspaper) and work in small (self-selected) groups to identify background, stakeholders, decision makers, and important timelines for the issues they have chosen. They then actively work to influence the outcome by writing letters, meeting with officials, attending and speaking at public meetings, and generating interest from others through media and other means. (...) Students have anecdotally reported increased understanding of the newspaper and local events, a much clearer understanding of who makes decisions and how to access them, and most importantly, confidence that they could get involved in an issue that interests them. (p. 574, my emphasis)