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ORIGINAL RESEARCH
diagnosis may have multiple meanings, diagnostically and people who are conventionally marginalized economically,
personally. racially, because of sexual orientation, geographic isolation,
Prior to commencing the study, the author had more than a illness or disabilities are not inevitably excluded from internet
decade as a nurse and counsellor in the sexual health field in technology.
New Zealand and anticipated recruiting women for face- The digital divide metaphor was contested in three studies
to-face (FTF) interviews. A literature review led to a change conducted in the United States of America (USA) by Mehra
in research method. Reports of in-depth email interviewing et al. (2004). They concluded that the digital divide had
used by nurses (Kralik 2000, Adler & Zarchin 2002, Tatano limited significance as the internet contributes to social equity
Beck 2005) and others within the social science field and empowerment. The studies addressed access of low income
(Illingworth 2001, McCoyd & Kerson 2006) highlighted families, sexual minorities and African-American women.
the benefits of this method when interviewing people who are Internet use in conjunction with a medical consultation is a
vulnerable and marginalized by a variety of health-related routine part of many peoples lives (e.g. Hay et al. 2008).
conditions. These researchers emphasized both suitability to Participants in online research are often recruited from a
participants of email over FTF interviews and the generation variety of online resources. People who experience stigma
of rich data. with a condition turn more readily to the internet than those
The author had relevant skills for email interviewing, as an who do not experience stigma. A USA survey (Berger et al.
email nurse-counsellor for two sexual health organizations. 2005) of 7014 people with a stigmatized condition demon-
In part, the decision to use email interviewing came from strated that this group was much more likely to use the
considerable experience as an email nurse counsellor, thereby internet than those with a non-stigmatizing health condition.
learning that it is common for people with health problems to Internet use involved information retrieval and contacting
use the internet for information, support and activism. There clinicians. Participation in ehealth online communities
is a familiarity with internet and email that often precedes the and social networks are part of the everyday experiences
decision to participate in online research. (Hamilton & Bowers 2006). These groups are readily
The study also used email interviewing with clinicians, but, accessible to people with minimal internet searching skills.
in these instances, the method was used for geographical The internet is not the domain of youth. In a USA study of
access and clinicians control over timetabling. This paper 2104 participants, Ybarra and Suman (2008) noted equal
addresses interviews with women with HSV/HPV as the numbers of adolescents and people 60 years and older using
method was used with these participants primarily to the internet to seek health information.
optimize discussion with potentially vulnerable participants. Women predominate in the area of seeking health infor-
mation online. An international online survey by Lagan et al.
(2010) concluded that it is commonplace for pregnant
Background
women to use the internet an adjunct to health care. Two
The internet has been harnessed to conduct health research USA studies (Dickerson 2003, Pandey et al. 2003) indicated
for a number of years (Mann & Stewart 2000). Liamputtong that womens traditional responsibility for family health was
(2007) argued that online research methods make research linked to internet use. The internet was an ally, with women
user-friendly to vulnerable populations by increasing their going online as part of family health management.
comfort and control. Examples of online health-related Researchers may turn to online recruitment when access is
interview methods include quantitative surveys (Cantrell & blocked by clinicians. In their North American study of
Lupinacci 2007), synchronous one-off online interviews in women who had terminated pregnancies subsequent to the
chat rooms (Davis et al. 2004), asynchronous one-to-one diagnosis of a foetal abnormality, McCoyd and Kerson
in-depth email interviews (McKeown et al. 2010) and online (2006) discussed the gate-keeping practices of clinicians
discussion groups (Kralik 2005, Guise et al. 2007). who either did not support the research project or controlled
Although online research methods may advantage vulner- which women were informed about the research. McCoyd
able populations participation, it is important for researchers and Kerson contend that the notion of protecting patients
to determine whether potential participants are able to access easily conflated with silencing women. Recruitment rapidly
the internet. The concept, digital divide, is used to critique expanded when research information was accessible to
potential obstacles to internet use and unequal access to women through posting an email request for participants
research participation opportunities (Lewis et al. 2005). on a relevant website.
Access disparities may include socio-economic, ethnic, gen- Similarly, in a Scottish study about womens use of
erational and gendered aspects. Lewis et al. contended that reproduction technology, Illingworth (2001) asserted that
power relations between researchers and clinicians may The recruitment advertisement was linked to the Home
impact adversely upon recruitment. She noted that research- pages of two websites of a government funded organization
ers dependence on clinicians for initial participant recruit- that provides information about HSV and HPV for clini-
ment may thwart researchers access to interviewing women cians and lay people in New Zealand. The websites have
FTF. She encountered clinicians gate-keeping, which led to considerable local and international traffic.
her decision to interview women by email. A webpage provided people with information about the
research and links to PDF documents of the participant
information and consent forms.
The study
The webpage was posted on the website of the university
where the research was undertaken. This link was impor-
Aims
tant to establish credibility.
This paper is the report of online recruitment and the data The advertisement with the webpage link was emailed to
collection method of email interviewing with women who academics and colleagues with a request to forward the
had a diagnosis of a viral STI. The paper highlights the email to their collegial and womens networks. A request
advantages of the email interviewing method to nurses where for participants was circulated on the emailing list of uni-
FTF research may be difficult for participants. versity students.
Data reached saturation before other recruitment options
were needed. When data saturation was achieved, the links
Design
were removed from the relevant websites and recruitment
A feminist, poststructuralist approach was used to explore ended.
what the diagnosis of a viral STI meant to womens lives, Email security: a designated email address for interviews
including the impact on healthcare experiences and their only was used and measures for internet security were
social and sexual lives. This approach was used because I reviewed. The participant information form gave partici-
wanted to understand the ways that these meanings or pants step-by-step information about the researchers
discourses affected womens sense of agency, both in management of data security and recommendations for
interactions with clinicians and with sexual partners. Burr their own management of the email correspondence to
described discourse as: protect their privacy. The details of these steps are available
elsewhere (Cook, 2009). The aim was to enable women
a set of meanings, metaphors, representations, images, stories,
with minimal computer literacy to participate and have
statements and so on that in some way together produce a version of
acceptable data security.
events (Burr 1995, p. 48).
enjoyment and care they took checking their replies and Cuban. The English participant was Caucasian, as were the
re-reading their comments prior to submission. two Canadian participants. All women corresponded in
English. Time since diagnosis ranged from 1 week to
Rigour 20 years. In analysing the interviewing method, the following
Rigour was established using Liamputtongs (2009) guide- themes were identified: internet familiarity, clarification,
lines for evaluating qualitative research. Liamputtong iden- staying on-track, sensitive topics, and disembodiment and
tified two key strategies: (i) design and method decisions, (ii) rapport building.
the participants, peer researchers and outsiders. Email inter-
views were selected to enable participation from those
women who might consider it impossible to participate FTF. Internet familiarity
Womens quotes were clarified before analysis. The
Most women reported the internet was a resource with their
researcher engaged in a reflexive process throughout the
diagnosis and they readily found the research advertisement.
interviewing process (Davidson & Tolich 2003). Reflexivity
Although the email interview experience was new to partic-
entailed journaling emotional and intellectual responses to
ipants, internet use was commonplace to access STI infor-
the interviews. Discussions with clinical colleagues and aca-
mation:
demic supervisors included analysing themes in the data and
addressing ethical obligations and potential conflicts in my When I used the internet I didnt have to worry about anyone seeing
intersecting roles as researcher, nurse and counsellor (Long & me as I have a laptop at home. To start with I just typed in the word,
Eagle 2009). herpes. Then I narrowed it down to herpes support, which then gave
The question of participant authenticity is an important me lots of sites to look at. There is a website where you can ask
aspect of data validity, which includes the extent to which questions or chat to people. I think online talking is very good as you
online and FTF data differ. The absence of non-verbal cues can speak to people in the same situation who are having the same
and participants opportunities to edit responses is arguably problems etc., as not everyone can get to a local support group or to
problematic (Mann & Stewart 2000). The researchers their doctors/health clinic to talk to anyone if they have a problem or
inability to read emotional cues is contested as a problem a question (Maddy, 24 years old)
in online research. Seymour (2001), whose participants lived
Most participants ranked the internet a more valuable source
with disabilities, asserted that FTF interviewing was a
of information than health professionals they consulted:
qualitative convention rather than a superior method that
disqualified online research. McCoyd and Kerson (2006), The internet has been my most used resource about HSV. Its
whose participants chose either email, telephone or FTF available 24 hours a day to answer any questions I have. Its provided
interviews, noted that email participants preferred that the most of the answers Ive needed about the virus (Miranda, 48 years
interviewer could not see emotional cues because they were old)
spared additional vulnerability.
The internet was appealing in terms of its affordability:
Authenticity is also about whether people are who they say
they are, for example, in terms of gender, age and life Actually I found the herpes website to be most informative as the
experiences. Mann and Stewart (2000) asserted that partic- doctor is too expensive just to go to for a chat (Claire, 29 years old)
ipants insider-knowledge is a possible test of authenticity.
Women typically believed they were able to evaluate online
Womens insider knowledge in this study appeared sustained
material for their benefit:
over the interviewing time-frame enabling the researcher to
have confidence over the probable genuineness of womens it has been through my own research on the internet, some good,
claims about their diagnoses. some bad that I have been able to get a handle on what the diagnosis
means for meto decipher the research that is out there and filter out
the propaganda and fear-based support groups (Victoria, 37 years
Results
old)
Twenty-six women with an HSV or a HPV diagnosis
participated in the interviews. Participants ages ranged from
Clarification
22 to 71 years of age. Seventeen resided in New Zealand and
of these 16 were of European descent and one identified as Receiving womens emails meant there were no time delays
Maori/European. Five participants were from USA. Of these, with transcription and participants comments were clarified
four described themselves as Caucasian and one as Latin/ in the researchers next reply:
no one could see meI think we have developed a relationship limited significance were less likely to be reading designated
despite the lack of visual feedback so I think it is a valid practice HSV/HPV websites and would not come across the research
(Dianne, 33 years old). (Hunt & McHale 2007). Women with more distress about the
diagnosis were likely to invest time and effort in the inter-
Dianne raised points that contradict the purported advanta-
views. Although participants reported valuing the method, it
ges of FTF interviews. She instead commented about the
is possible that significant data were missed through the
intrusiveness of body language and the potential disruptive-
absence of non-verbal cues (Hamilton & Bowers 2006).
ness of the interviewer to her train of thought. She considered
The findings show that email interviews may be a valuable
that the opportunity to edit her writing enhanced her
data collection tool to interview people who are marginal-
contribution.
ized. The concept of sensitive research (Liamputtong 2007)
I think the interview online is better than a face-to-face one.Just my shaped the interview process. Sensitive research includes any
personal opinion, but a face to face interview would in a sense give research where the participants disclosures involve real or
less information. I think I would be just smiling and nodding my head potential risk of harm, physically, emotionally or legally.
to any questions you hadQuite simply, I would be discussing my Women with HSV/HPV are part of a socially diverse hidden
private parts with a stranger, and perhaps that has never really been population. Interviewing women who have contracted a viral
done for more than just clinical analysis (Rachel, 28 years old). STI involves asking women about aspects of their health,
sexuality and relationships that are deemed private. Womens
Rachels point about imagining smiling and nodding at the
disclosures about sexuality and sexual health are potentially
interviewer highlight that there is nothing intrinsically
discrediting, given the stigma associated with viral STIs
superior about interviewers subjective impressions of inter-
(Bickford et al. 2007, Waller et al. 2007). Additional com-
viewees. The absence of FTF contact spared women poten-
munication skills and cognisance of ethical complexities are
tially stressful parts of the interview process and enhanced
required by researchers when engaging in sensitive research
contributions. Women commented on helpful and at times
(Dickson-Swift et al. 2008).
transforming aspects of participation:
In this study, womens enthusiasm for email compared with
The research process, and corresponding with you, was very cathartic FTF interviews reflects other research findings. In an Austra-
for me. It helped me organise my thoughts in a coherent manner and lian study, Seymour (2001) argued internet-based interviewing
address issues that were bothering me. It also helped me, through a enabled more egalitarian research practices with people with
process of self-discovery, to put HPV in context (Ann, 36 years old). disabilities who were more able to speak their experiences
through email rather than in FTF interviews. There were fewer
There has been great value for me in doing the research. You have
hurdles as participants controlled contact and interview
responded to what I have written in a helpful and healing way. I at
location. Similarly, in an Australian study using email inter-
last feel I have a voice and have been heard.I was certainly more
views with people who had a traumatic brain injury, partic-
forthcoming with the specialist due to being involved with your
ipants preferred email rather than FTF interviews (Egan et al.
research and I am more confident to speak my truth (Jane, 71 years
2006). Cognitive-linguistic impairments were less intrusive for
old).
participants, who preferred the open time-frame, comfort of a
As a nurse with many years of FTF and online counselling familiar environment and keeping track of the interview
experience, the researcher assessed that data were not without relying on memory. Egan et al.s findings illustrate
compromised through the collection method. that FTF interviews may disadvantage participants and impact
adversely on data quality. In Kraliks (2000) Australian-based
study of women with long-term illnesses, email interviews
Discussion
enabled inclusion of women who would otherwise have been
Email interviewing had limitations as a research method. excluded due to rural isolation or illness. Email interviews
Women were not offered alternative interview methods and provide inclusiveness not possible in the flesh.
due to this, some may have chosen not to participate. The Women emphasized the ease with which they disclosed
study included only a small number of women with enough personal information in their emails. This aspect of email
computer ability and English literacy to participate. The interviewing is not unproblematic for participants and
participants were not ethnically diverse even though there was researchers. Mann and Stewart (2000) and Liamputtong
international participation. Participants were unlikely to (2009) have alerted researchers to the potential risks of
represent the breadth of experiences of women with viral participants over-disclosure online; communicating in a far
STIs. For example, women for whom the diagnosis is of less guarded manner with a stranger than they might FTF.
For this reason, each participant was advised that they could
withdraw any aspects of the interview from the research, as Conflict of interest
well as the researcher using discretion to withhold potentially No conflict of interest has been declared by the author.
identifying material from publication. Participants were also
welcome to make comments and to ask questions off the
record. References
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