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Gudrun Stummer: Research Proposal Submission
2007
A
reflective action research project to
investigate the development of an
educational public health web site with an
integrated online advice service
Introduction
Over the last 15 years the internet has
become a significant part of many people’s
lives in the Western world and beyond. It
has revolutionised access to information for
those of us, who can go online. However,
despite the reach of the internet today, it
is seldom used for professional interactive
health advice or social support, and even
less often researched if it is. The
following action research project aims to
investigate the steps necessary in setting
up and running a low cost educational public
health web site. The research will use the
project ‘sex-and-relationships.com’ as a
case study. In-depth technical aspects of
web design or internet technology will not
be investigated in this study.
The Case Study Project
The project sex-and-relationships.com has
been running for about 2 years at the start
of this study in January 2006 in a
rudimentary form. The project has been set
up by 2 people, the author being one of
them. The initial idea was to team up as
male and female co-authors and to write
easily accessible texts on sexual health and
relationship issues to offer preventative
public health and social interventions for
people on the internet. The project appealed
to our political agenda of respectful and
global feminism. Additionally, the project
opened up the opportunity to use the
professional skills of a registered
psychotherapist to support people beyond the
immediate vicinity.
Its global reach and anonymous access means
it is possible to offer advice services to
people, who may not otherwise be able or
willing to access this type of service. In
focusing on sexuality and relationship
issues we hope to harness the power of the
internet to deliver information and advice
anonymously on difficult emotional issues,
which people may otherwise not feel able to
talk about. Finally, the project itself
requires very little ongoing expenditure
except time, bringing it within reach of
small organisations. It can also earn
revenue via affiliate programmes and
advertising making it independent from
grants whilst offering high quality
information for free on the internet.
Theoretical Context
The research with sex-and-relationships.com
operates within a multidisciplinary field.
Whilst focusing on service development
through professionalizing action research
(Hart and Bond 1995), other areas need to be
accounted for, such as the internet, the
politics of sexual health, cultures and
gender roles worldwide, queer theory,
psychosexual interventions, online
counselling and online research issues. All
of these areas impact the project and need
to be integrated in a meaningful way for the
action research to fulfil pragmatic
concerns. However, within the project itself
the researcher-as-project partner
concentrates on the quality of content and
the provision of psychological services in
her capacity as a psychotherapist, whilst
the other team member deals more directly
with basic technological issues and the
internet. Therefore, I want to restrict my
preliminary literature review within this
proposal on the topics of psychosexual
interventions and online counselling.
Psychosexual and relationship therapy
The field of psychosexual therapy has been
fragmented theoretically and
organisationally and is only slowly moving
towards an integration of theory (Weeks
2004) as well as an organisational
integration with other fields of
psychotherapy. Historically, Freud
introduced the importance of sexuality into
our awareness, but later generations of
psychotherapists managed to distance
themselves from it again by focussing more
on the mother-baby dyad and less on adult
relationships (Cornell 2002).
Theoretically, psychosexual therapy was
closely linked to the medical model and
behavioural interventions. The first modern
psychosexual manual by Masters and Johnson
(1970) is based on a medical model of sexual
dysfunction and it recommends homework
assignments, which are behavioural
interventions to cure sexual dysfunction.
There are some attempts at a systemic
perspective as Masters and Johnson (1970)
include the partner of the client within
their diagnosis. Other writers follow this
model with few additions (Kaplan 1974,
Hawton 1985, Leiblum and Rosen 2000). An
exception are Daines and Perrett (2000), who
approach psychosexual issues from a more
psychodynamic perspective, and Weeks and
Gambescia (2000 and 2002) and Weeks et al
(2003), who integrate marital therapy with
its systemic perspective into their approach
to psychosexual interventions.
Online counselling and advice
Online counselling is a very recent
development starting in the mid 1990’s
(Anthony 2003). Although some books have now
been published on this subject (Bloom and
Walz 2004, Kraus et al 2004, Goss and
Anthony 2003, Hsiung 2002, Bloom and Walz
2000, Fink 1999), comparatively little has
been written about online counselling and
few research projects have yet looked into
this new practice. The counselling community
seems divided over the usefulness of the new
medium (see Rochlen, Zack and Speyer 2004
for an overview) for counselling. Possible
disadvantages, which are debated, include
missing non-verbal communications, problems
with establishing a therapeutic relationship
online, opportunities for misunderstandings,
time delays, the need to be computer
literate, vulnerability of data sent over
the internet, cultural clashes and the
possibility for misrepresentation of
identity. Advantages, which are discussed in
favour of the new medium include its ease of
access, an additional sense of security for
the client due to the counsellor being one
step removed, and the opening up of a
reflective space through writing. However,
apart from discussions in the professional
communities, what seems to be emerging is a
clear demand for advice over the internet
with the Samaritans, for example, receiving
and responding to 36,500 emails in 2000 and
72,000 in 2002 (Hanley 2005).
I believe that an online advice service on
sexual health and relationship issues is in
line with the newly emerging practice of
online counselling. Furthermore, I believe
there are specific advantages for offering
this type of service on the internet (Cooper
et al 2002). Firstly, an online service can
offer easy access to information to anybody
who can go online, making it a low threshold
service. Secondly, due to the lack of travel
costs and other overheads involved it will
be a low cost service. Thirdly, clients may
feel safer talking about difficult issues
using the anonymity of the internet as well
as within an online counselling relationship
in which the therapist is one step removed
from the client. This may well be of great
importance, as people often experience great
difficulty when talking about sexuality and
relationships.
Rationale for the action research project
‘Definition
of Sexual Health: Sexual health is an
important part of physical and mental
health. It is a key part of our identity as
human beings together with the fundamental
human rights to privacy, a family life, and
living free from discrimination. Essential
elements of good sexual health are equitable
relationships and sexual fulfilment with
access to information and services to avoid
the risk of unintended pregnancy, illness or
disease.’ (Department of Health 2001)
Sexual health is an important national and
international concern (Department of Health
2001 and 2005, BBC1 programme Panorama ‘Love
Hurts’ 2005). Sexual health in a broad sense
covers a wide field including contraception,
sexually transmitted infections (or STIs)
and unwanted pregnancies, as well as healthy
sexual expression and bonding in couples.
Sexual health is closely linked to
relationship skills and emotional literacy.
Most of us deeply value our intimate
relationships, yet we are often unprepared
for the challenges they present us with.
The internet offers an easily accessible and
anonymous way of offering advice and
counselling on sexual health and
relationship issues to individuals.
According to the recommendation of the
Independent Advisory Group on Sexual Health
and HIV, prevention and education are key
strategies to deal with sexual health issues
(Department of Health 2004). Traditional
services such as GUM clinics are already
unable to cope with demand and may need an
increase in capacity of 30 – 50% (Dr. White,
quoted in BBC1 2005) to keep abreast of new
infection rates. New approaches and
unconventional services, which allow for a
quick and anonymous way to access advice,
may be able to fill the gap in educative and
preventative services to some extend.
Innovation within the field of health
education is important to promote access and
take up of essential services. However, new
initiatives need to be developed according
to best practice guidelines and have some
level of evaluation of practice. Within the
NHS evidence based practice is key to
clinical excellence and accountability of
service provision (Brownson et al 2003).
Action research can help to make sense of
problems encountered during service
development and encourages continual
critical reflection, which can lead to best
practice in health and social care (Hart and
Bond 1995). The proposed action research
project focuses on facilitating the
development of the service and aiming at a
high standard of delivery. It hopes to
document obstacles encountered during
development and early running of the service
and to report on potential solutions, which
were tested. It can be placed within the
professionalizing approach to action
research (Hart and Bond 1995). In accordance
with the emergent nature of action research,
detailed research questions will be
formulated throughout the research project
through an iterative process.
The general research questions are as
follows:
-
What
are the steps involved in developing and
running a low-cost, educational public
health web site? (Excluding in-depth
technical aspects of web design or
internet technology)
-
What are the
important factors encountered during
development and running of the service?
-
What kinds
of obstacles are encountered and what
possible solutions are tried and
evaluated in the case study project?
-
What is the
reflexive learning of the
practitioner-researcher during the
process?
The following overall objectives for the
action component of the research project
will act as guidance for the development of
more detailed action steps:
Objectives for practical interventions:
-
Improve the
web site and advice service through
action research along the following
parameters: Accessibility through search
engines on the internet, range and
accessibility of content of materials,
respect for culture, gender equality and
non-heterosexual lifestyles, global
take-up, interactivity and
participation, high quality of
information and advice, and
sustainability.
-
Open a space
for critical reflection on the service,
which invites participation by service
users, colleagues and the wider
community.
Methodology
Action Research
Action research is a form of qualitative
research, which combines practical
interventions with fact finding and critical
reflection within a cycle of enquiry and
action (Lewin 1946 and 1948, Elliott 1991,
Costello 2003). Through its action and
research components action research lends
itself towards managing a process of change,
such as establishing a new service (Hart and
Bond 1995) or changing practice (Elliott
1991, Kemmis and McTaggart 1992). The
methodology itself warrants action and
practical solutions as well as critical
reflection and analysis. Therefore, action
research is unique in the fact that it aims
to close the theory-practice gap at a
conceptual level as well as a practical one
(Rapoport 1970).
Within my exploration of action research I
have drawn on Carr and Kemmis (1986: 162),
who see action research as a form of
‘self-reflective inquiry’ towards improving
practice with a view of maximising social
justice. Additionally, I have been
influenced by other writers interested in
professionalizing practice such as Elliott
(1991), Nixon (1981), Stenhouse (1975) with
his idea of the ‘teacher-as-researcher, and
Schön (1983). With respect to the action
research cycle I have found Altricher and
Gstettner’s (1993: 343) model
conceptualising action research in four
steps useful: a) finding a starting point,
b) clarifying the situation, c) developing
action strategies and putting them into
practice, and d) making teacher’s knowledge
public. Their cycle seems to reflect the
practical concerns for my research well,
however it lacks an emphasis on research and
analysis, which is better reflected in
Zuber-Skerritt’s (1996: 84) model of action
research: a) strategic planning, b)
implementing the plan, c) observation,
evaluation and self-evaluation and d)
critical and self-critical reflection on the
results. Further ideas in action research,
which I have found useful are the importance
of feedback within and between each cycle (Ebbutt
1985), that sometimes clusters of action
steps need to implemented at the same time
(Elliott 1991) and that analysis is an
ongoing process (Elliott 1991).
Action research is highly participatory
(Reason and Bradbury 2001). It aims to
involve others in the research project and
opens up the research to outside ideas and
influences. As such it is congruent with my
epistemological approach, which is
constructivist, seeing the world in general
and that of human interaction in particular
as an outcome of the interaction of an
objective world and meaning making subjects
(Crotty 1998). I am also highly indebted to
pragmatism as a way of thinking about
validity and systems thinking (Flood 2001).
I see the latter as necessary to hold in
mind the whole project, which can only work
in practice when approached as a whole.
Validity and reliability
With regards to the validity of the proposed
action research project, I would like to
take a view between quantitative criteria of
validity such as generalisability,
objectivity and replicability and the notion
that action research is a subjective and
singular event, which does not need to prove
validity to an outside observer (Rolfe
1996). The creation of criteria for validity
in qualitative research is a long-standing
debate. What seems to have emerged is a
recourse to certain tactics such as the use
of triangulation, respondent validation,
clear exposition of methods of data
collection and analysis, sometimes referred
to as transparency, and reflexivity (Robson
1999, Pope et al 2000) to name but a few.
Hope and Waterman (2003) discuss further
criteria for action research, in particular
validity based on pragmatism.
The design of my project already
incorporates some of the criteria debated
with regards to validity in qualitative
research. Through the use of a female
researcher and a male project partner, an
element of dialogue and shared critical
reflection about the project is introduced
into the research. Additionally, this is
also the start of a participatory approach,
which I hope to expand by developing the
interactive components of the project.
Furthermore, I consider a reflexive
component to my research an important part
of the overall project, which will
contribute to the validity of the action
research (Etherington 2004b).
Action research is flexible as to what types
of data are used for evaluation and
analysis. With respect to this project both
quantitative and qualitative data are
important. Therefore, this project uses a
mixed methods approach to data gathering (Tashakkori
and Teddlie 2003, Creswell 2003). I envisage
quantitative and qualitative data to
complement and expand on each other (Newman
et al 2003). Quantitative and qualitative
data will be collected concurrently, but
also sequentially as part of subsequent
action research cycles.
Furthermore, all data collected through the
project needs to be located within a
constructivist and interpretive framework.
The project operates within the disembodied
environment of the internet, which can hide
identifying factors such as name, sex, race,
age or social class. Data collection will be
limited to online means only to be congruent
with the project itself. Therefore, the web
site is the target of the research and at
the same time the only connection to
participants and the main data gathering
tool. Research participants approach us as
we have something to offer them as in
clinical inquiry (Schein 2001), but we only
get to know them through their exchange with
us or a trace of data showing somebody has
visited the site. Their true identities are
not revealed and the researcher has no
possibility of verifying the data
participants provide. Additionally, the web
site itself is made up of text, which tells
a series of stories about sexuality and
human relationships. There are many
opinions, taboos, cultural myths and other
‘stories’ woven into our text (West and
Talib 2002). As such I see the researcher as
a true ‘bricoleur’ (Denzin and Lincoln 1994)
approaching research as a narrative.
Types of data collected
Quantitative data
Quantitative data, which are available about
the service, are mainly gathered through a
web site management tool called Google
Analytics. It monitors web sites and offers
quantitative data such as numbers of total
visitors, location where they have logged in
from, referral source and a list of top
ranking pages visitors have accessed. The
data is collated through placing ‘cookies’
or markers on the computers of visitors to
our site. However, some people delete
cookies or disable the facility in which
case, they are not picked up by Google
Analytics. Within the web hosting community
it is generally suggested to treat Google
Analytics figures with a +/- 10% range of
accuracy.
Other sources of quantitative data are the
number of incoming web links to the site,
which are directly linked to how the site is
ranked with Google. This makes the number of
incoming links an important quantitative
figure. The number of incoming web links can
be established through a Yahoo search.
Additionally, precise figures can also be
taken for the site itself such as numbers of
pages, numbers of outgoing links or numbers
of posts on the research blog.
Furthermore, quantitative data is being
collected through the use of an online
survey (ASP survey software), which visitors
to the site can click on and complete. The
survey contains questions about demographic
data such as location, age and sex of
participants, and sexual orientation. Two
additional pages in the survey ask questions
about specific themes such as accessibility
of the language we use to write materials.
Each research participant is only allowed to
access the survey once by the software.
However, participants are self selected and
cannot be assumed to be representative of
all visitors to the site.
Finally, quantitative data is created
through our email advice service. I record
how many emails I receive, how many
subsequent emails are exchanged and how long
it takes me to answer each query. (We have
received 20 email queries in 2006 and 20
email queries between the 1.1.07 and the
10.6.07). Additionally, I have set up a
follow-up online survey to evaluate my email
advice work with people. I send out a link
for the survey within one week after
answering a query via email. After starting
the feedback process in Spring 2006 we have
received 9 responses to it in 2006
To facilitate a clear structure for my
research project whilst staying committed to
a systemic approach, I have decided to use
specific quantitative and qualitative
“indicators” to help me evaluate whether my
action interventions develop the project
along the objectives for practical action
interventions.
Quantitative indicators for evaluation of
actions taken:
-
Number of
visitors to the site.
-
Number of
web pages.
-
Number of
incoming links
-
Number of
email queries
-
Location of
visitors.
Qualitative data
Qualitative data is of great importance to
the project as it allows me to gain insight
into how service users interact with the
project, what it means to them and how the
service can be improved. Qualitative data is
generated through the online survey software
on specific topics. Up to now I have
completed surveys asking for general
comments by participants, questions about
accessibility of language and currently
information on sex education and culture.
All surveys combine closed and open
questions, as well as offering unlimited
space for any further comments participants
may want to leave us. In total, including
surveys participants contributed through the
email advice feedback survey, I have
collected more than 200 entries up to now.
Additionally, qualitative data is created
through the email advice service. This gives
insight into what participants struggle
with, what they want from us as a service
and whether we have helped them or not. It
also allows us a view into the world of our
participants, their lives, relationships and
general concerns. I use my skills as a
psychotherapist to offer participants a
service as well as gather rich data in the
process (Schein 2001).
Qualitative data is also created through the
ongoing dialogue between project partners.
Most of our exchanges are via email with the
occasional phone call and face to face
meeting, which I take notes on. This data
will give important information as to how
the project was established, what problems
were encountered and tackled, and what our
dialogue focused on at different times (Frankham
and Howes 2006).
I believe an important strand of data for
the research will be my own critical
reflection on the project (Moustakas 1990,
West 1998 and 2001, Etherington 2004a and
2004b). Given that the research is located
within a field of constructed narratives, my
own story about the project and the research
is an important element of the whole. To
develop my own reflexive practice congruent
with the project, I am writing an online
research journal in the form of a blog
(http://www.sex-and-phd.com). Blog software
enables online journal writing in the form
of individual posts. Each post contains a
heading, can include hyperlinks to other
resources on the web and can be assigned to
different categories to allow for selective
reading of strands of posts. The blog has
been a useful tool to help me contain all
the different thoughts, reflections and
facts I have encountered so far. I have used
my blog to take notes on all the literature
I have read, keep ideas for further
development of the research or hyperlinks to
articles I have found in newspapers, which
have political relevance to the project.
Additionally, the blog is a public forum and
is accessible from the web site via a link.
Visitors to the blog can leave comments and
engage in dialogue with me about the action
research project. Furthermore, the blog has
become a management tool for my colleague
and myself to structure our work schedule
for the project. Occasionally, there are
issues, which I do want to reflect on in
private and I have a personal, much shorter
research journal for that purpose.
Qualitative indicators for evaluation of
actions taken:
Data Analysis
Quantitative, qualitative and reflexive data
collected for the project need to be
analysed and integrated at points throughout
the project. Data will be analysed
separately and then compared and contrasted
with other findings to inform subsequent
planning and action in the action research
process (Elliott 1991, Cohen et al 2000,
Hanson et al 2005). All of the quantitative
data can be analysed with simple descriptive
statistics, which is congruent with the
pragmatic approach. Some of the qualitative
data will be categorised and counted such as
which topics participants wrote to us about
and analysed through content analysis
(Silverman 2001, Creswell 2003). I also
think that it will be useful to let themes
arise as in grounded theory, however
strictly speaking the research design will
not allow for a correct application of this
type of analysis, due to my ongoing reading
and involvement in the subject matter.
An initial point of analysis and integration
often happens through my reflective writing
for the blog. Here I use a category called
‘analytic memo’ to track my reflection on
data. The blog also constitutes a readily
accessible audit trail, which allows access
to a chronological record of the project and
the way I construct meaning out of the data.
An additional point of integration and
analysis is the dialogue with my project
partner about the findings of the research.
Ethical Considerations
Research involving human participants always
generates ethical issues (McLeod 1994).
Ethical research practice is centred on
gaining informed consent for research. Other
general issues around ethical research are
trustworthiness of the researcher, managing
possible risks involved in the project, data
protection and anonymity and the integrity
and quality of the research (Bond 2004).
The ethical guidelines, which I want to
utilise for my project are Bond (2004) for
research ethics and Goss et al (2001) for
online counselling, covering both research
and online work. Furthermore, I envisage
particular ethical issues to arise from
using the internet to gather data (Plaut and
Donahey 2002, Mann and Stewart 2002). For
example, informed consent becomes more
difficult to establish over the internet. It
is impossible for the researcher to
establish for certain participants’ real
identity or their competency to give
consent, but on the other hand it is
incongruent with the overall project to
collect written signatures on paper (Mann
and Stewart 2002).
Another major ethical consideration in this
project is data protection and
confidentiality. Due to the nature of the
internet confidentiality can not be assured
for data, which is in transit unless it has
been encrypted (Mann and Stewart 2002),
which is especially important with respect
to the email advice service. Moreover, data
held electronically is subject to data
protection legislation (Mann and Stewart
2002). I have addressed these ethical issues
by operating the email advice service within
complete anonymity asking participants to
write from an anonymous email account. This
also ensures that the data is not subject to
the Data Protection Act as it is not linked
to an identifiable individual. The guidance
on the email advice service offers all
participants the option to state if they do
not want their email to contribute to the
research project, without it impeding their
access to the service.
Contribution to academia and beyond
New and innovative public health projects
may be able to lessen some of the shortages
in the provision of preventative health and
social interventions we face today. However,
few studies have yet enquired into how such
innovative services could be set up and run
(Hahn 1998, Sciamanna et al 2002, Benegeri
and Pluye 2003, Hall 2004, Papadaki and
Scott 2006). This study aims to use a case
study project to gain insight into how a low
cost public health service could be set up
and run via the internet. The study hopes to
provide other agencies, which are thinking
about developing their own internet outreach
service, but have little funding available,
with one specific case study analysing the
processes involved in the development and
running of a low-cost online service.
Considering the increased availability of
internet facilities beyond the Western
world, but also the desperate lack of
funding for preventative health projects
worldwide the author hopes to generate
knowledge for non-governmental organizations
beyond the West, who want to use innovative
approaches, but who are not able to marshal
significant funds.
Additionally, the author hopes that the
research will appeal to a wide range of
academic audiences such as the psychotherapy
and counselling community, as well as action
researchers and public health and
educational experts. Potential journals,
which may be interested in publishing this
study are ‘Counselling and Psychotherapy
Research’, ‘Health Promotion International’,
‘Health Education Research’, ‘Sexual and
Relationship Therapy’ or ‘Educational Action
Research’. Furthermore, the author hopes to
integrate some of the research findings into
the project itself and thereby publishing
the findings on the internet as well as
write for new online journals to develop the
internet as a place of academic endeavour.
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