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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Jossey-Bass Public Health/Health Services Text
- Sprache: Englisch
Qualitative Methods in Public Health: A Field Guide for Applied Research, 2nd Edition provides a practical orientation to conducting effective qualitative research in the public health sphere. With thorough examination and simple explanations, this book guides you through the logic and workflow of qualitative approaches, with step-by-step guidance on every phase of the research. Students learn how to identify and make use of theoretical frameworks to guide your study, design the study to answer specific questions, and achieve their research goals.
Data collection, analysis, and interpretation are given close attention as the backbone of a successful study, and expert insight on reporting and dissemination helps you get your work noticed. This second edition features new examples from global health, including case studies specifically illustrating study design, web and mobile technologies, mixed methods, and new innovations in information dissemination. Pedagogical tools have been added to help enhance your understanding of research design and implementation, and extensive appendices show you how these concepts work in practice.
Qualitative research is a powerful tool for public health, but it's very easy to get it wrong. Careful study design and data management are critical, and it's important to resist drawing conclusions that the data cannot support. This book shows you how to conduct high-quality qualitative research that stands up to review.
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Veröffentlichungsjahr: 2016
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Table of Contents
Title Page
Copyright
Dedication
List of Figures, Tables, and Boxes
List of Case Studies
Foreword
Reference
Acknowledgments
About the Authors
Chapter 1: Invitation to Explore
Our Purpose
What Is Qualitative Research?
Getting Started
Key Terms
Review Questions
References
Chapter 2: The Language and Logic of Qualitative Research
Frameworks for Research: Paradigms, Theories, and Conceptual Models
Using Qualitative Methods to Develop Theory
Substantive Theories and Conceptual Models
Standards for Qualitative Research
Summary
Key Terms
Recommended Readings
Review Questions
References
Chapter 3: Designing the Study
Background and Rationale
Developing Study Objectives
Using Documentary Sources
Data From Human Subjects
Data Collection Methods
Collecting Data
Analyzing the Data
Disseminating Results
Research Ethics: Decisions for the Protection of Study Participants
Other Considerations: Budget and Time
Summary
Key Terms
Recommended Readings
Review Questions
References
Chapter 4: Collecting Qualitative Data: The Science and the Art
Observation
Interviews and Focus Groups
Structured Data Collection Techniques
Summary
Key Terms
Review Questions
Recommended Readings
References
Chapter 5: Logistics in the Field
Introduction to the Community: Building Rapport
Involving Policymakers and Change Agents
Developing the Field Team
Training
Field Materials
Pilot Testing
Field Logistics
Supervision and Monitoring
Generating Data Files
Transcription and Translation
Data Management and Storage
Timelines and Budgets
Summary
Key Terms
Review Questions
Recommended Readings
References
Chapter 6: Qualitative Data Analysis
Basic Steps in Qualitative Data Analysis
Step 1. Reading: Developing an Intimate Relationship with the Data
Step 2. Coding: Identifying the Emerging Themes
Computer Software
Step 3. Displaying Data: Distinguishing Nuances of a Topic
Developing Hypotheses, Questioning, and Verifying
Step 4. Data Reduction: Getting the Big Picture
Step 5. Interpretation
Establishing Trustworthiness
Summary
Key Terms
Review Questions
Recommended Readings
References
Chapter 7: Disseminating Qualitative Research
Research Ethics Require Dissemination
An Inclusive Dissemination Process Promotes Use
How to Develop a Communication and Dissemination Strategy
Choosing a Format for Dissemination
Summary
Key Terms
Review Questions
Recommended Readings
References
Chapter 8: Putting It Into Words: Reporting Qualitative Research Results in Scientific Journals and Reports
The Role of Writing in Responsible Conduct of Research
Before You Write
Writing Your Article or Report
After You Write
Summary
Key Terms
Review Questions
Recommended Readings
References
Appendix 1: Case Studies
References
Supplemental Case Study Materials
Supplemental Case Study Materials
References
Supplementary Case Study Materials
Supplementary Case Study Materials
References
Supplemental Case Study Materials
References
Supplemental Case Study Materials
Supplementary Case Study Materials
Supplementary Case Study Materials
References
Supplemental Case Study Materials
References
Supplemental Case Study Materials
References
Supplementary Case Study Materials
References
Supplementary Case Study Materials
Appendix 2: Examples of Oral Consent Forms
Example 1: Acceptability of Six-Month Injectable Contraception
Example 2: Communicating About Microbicides With Women in Mind
Appendix 3: Participant Observation Notes
Example 1
Example 2
Appendix 4: Topic Guides With Pictures
Topic Guide for Consultations With Program Implementers and Service Providers
Topic Guide for FGDs With End Users
Appendix 5: Sample Interviewer Training Program Agendas and Training Schedules
Techniques for Conducting In-Depth Interviews and FGDs
Required Reading
Appendix 6: Sample Budget Categories for Planning Qualitative Data Collection
Appendix 7: Coding Summary Report
Internals\FGD\FGD#1 with Mothers in Tanzania
Internals\FGD\ FGD#1 With Sexual Partners in Tanzania
Internals\KI\Tanzania Key Informant #6, From Education
Internals\MTN\1st of Several Interviews With a Tanzania Married Teen #11
Internals\MTN\2nd Interview With the Same Married Teen #11
Appendix 8: Example of Data Analysis Memo
Appendix 9: Making Study Findings Accessible to Other Researchers
Cataloging Information
Bibliographic Indexing Databases and Information Clearinghouses
Depositing Datasets
Websites
Appendix 10: Dissemination materials for community stakeholders
Research Briefs
Example 1. Narrative Format
Example 2: IMRAD Format
Example 3: Newsletter
Appendix 11: Sample Briefs to Share Qualitative Study Findings with Policy Audiences
Example 1
Example 2
Notes
Appendix 12: Sample Dissemination Strategy for Advocacy
Appendix 13: Where to Publish
Journals
Appendix 14: Who Is an Author?
Index
End User License Agreement
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Guide
Cover
Table of Contents
Begin Reading
List of Illustrations
Chapter 7: Disseminating Qualitative Research
Figure 7.1 Strategic Communications Plan
Figure 7.2 Flyer Disseminating Results from the LinCS 2 Durham Study to the Community
List of Tables
Chapter 2: The Language and Logic of Qualitative Research
Table 2.1 Three Paradigms for Public Health Research
Chapter 3: Designing the Study
Table 3.1 Common Elements of a Research Proposal
Table 3.2 Summary of Sampling Approaches
Table 3.3 Structural Differences in Qualitative Data Collection
Chapter 7: Disseminating Qualitative Research
Table 7.1 Community Dissemination Formats and Audiences for the LinCS 2 Durham HIV Prevention Study
QUALITATIVE METHODS IN PUBLIC HEALTH
A Field Guide for Applied Research
Second Edition
ELIZABETH E. TOLLEYPRISCILLA R. ULINNATASHA MACKELIZABETH T. ROBINSONSTACEY M. SUCCOP
Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved.
First edition Qualitative Methods in Public Health: A Field Guide for Applied Research by Priscilla R. Ulin, Elizabeth T. Robinson, and Elizabeth E. Tolley © 2005
Published by Jossey-Bass A Wiley Brand One Montgomery Street, Suite 1000, San Francisco, CA 94104-4594— www.josseybass.com
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read.
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Library of Congress Cataloging-in-Publication Data
Names: Tolley, Elizabeth E., author.
Title: Qualitative methods in public health : a field guide for applied research / Elizabeth E. Tolley [and four others].
Description: Second edition. | San Francisco, CA : Jossey-Bass & Pfeiffer Imprints, Wiley, 2016 | Series: Jossey-Bass public health | Revision of: Qualitative methods in public health / Priscilla R. Ulin, Elizabeth T. Robinson, Elizabeth E. Tolley. c2005. 1st. ed. | Includes bibliographical references and index.
Identifiers: LCCN 2015042723 (print) | LCCN 2015042794 (ebook) | ISBN 9781118834503 (paperback) | ISBN 9781118834671 (pdf) | ISBN 9781118834657 (epub)
Subjects: LCSH: Public health–Research–Methodology. | Qualitative research. | BISAC: MEDICAL / Public Health.
Classification: LCC RA440.85 .U43 2016 (print) | LCC RA440.85 (ebook) | DDC 362.1072/1–dc23
LC record available at http://lccn.loc.gov/2015042723
Cover Design: Wiley
Cover Image: © Click Bestsellers/Shutterstock
Dedicated to Andy Pasternack—our Jossey-Bass editor whose vision and encouragement inspired the first edition of this book.
List of Figures, Tables, and Boxes
Figures
Figure 7.1
Strategic Communications Plan
Figure 7.2
Flyer Disseminating Results from the LinCS 2 Durham Study to the Community
Tables
Table 2.1
Three Paradigms for Public Health Research
Table 3.1
Common Elements of a Research Proposal
Table 3.2
Summary of Sampling Approaches
Table 3.3
Structural Differences in Qualitative Data Collection
Table 7.1
Community Dissemination Formats and Audiences for the LinCS 2 Durham HIV Prevention Study
Boxes
Box 1.1
Characteristics of Qualitative Research
Box 2.1
Checklist for Evaluating Substantive Theory
Box 2.2
Social Ecological Model and the Position of Substantive Theories Along Concentric Levels of Aggregation
Box 3.1
Conceptual Framework: Social Drivers of Adoption of Improved Cook Stoves
Box 3.2
Common Ways to Mix Methodologies
Box 3.3
Priority-Sequence Model: Decisions for Integrating Methods
Box 3.4
Some Federal Requirements for Informed Consent
Box 4.1
Guidance for Conducting Direct Observations
Box 4.2
Using Participant Observation to Identify Recruitment Sites at Bars and Other Establishments for an HIV-Prevention Clinical Trial With Women
Box 4.3
Suggestions for How to Write Field Notes From Participant Observations
Box 4.4
Process for Constructing a Semi-Structured Question Guide
Box 4.5
Types of Qualitative Research Questions
Box 4.6
Levels of Interview Questions in a Qualitative Study of Emergency Contraception (EC)
Box 4.7
Deciding How Many Focus Groups to Conduct
Box 4.8
Collecting Background Information From Interview and Focus Group Participants
Box 4.9
Characteristics of a Good Interviewer or Moderator
Box 4.10
Common Errors in Focus Group Moderating
Box 4.11
Steps to Conducting a Focus Group
Box 5.1
Developing a Risk Management Plan
Box 5.2
Technology and Qualitative Research
Box 5.3
Illustrative Budget Considerations
Box 6.1
Qualitative Data Analysis: Step by Step
Box 6.2
Noting Content in Transcripts: An Excerpt From an Interview With a Peer Educator and Sex Worker
Box 6.3
Transcript Excerpt and Emergent Codes
Box 6.4
Preliminary Codebook
Box 6.5
Application of the Code “Conflict” by Two Coders
Box 6.6
Qualitative Intercoder Reliability Matrix
Box 6.7
What to Look for in Software for Qualitative Data Analysis
Box 6.8
Coding Report on Conflict
Box 6.9
Memo on Sexual Behavior
Box 6.10
Data Reduction Matrix Based on Sexual Behavior Coding Report
Box 6.11
Using a Diagram to Organize Findings
Box 7.1
Ways to Foster Two-Way Communication in Research
Box 7.2
Checklist: Elements of an Effective Communication and Dissemination Plan
Box 7.3
Working With the Media
Box 7.4
Using Social Media to Share Research
Box 7.5
How to Make Study Findings Accessible
Box 7.6
Dissemination Factors That Promote Utilization
Box 7.7
Policy Dissemination Tips
Box 8.1
How to Organize a Standard Scientific Article or Report
Box 8.2
Content Checklist: What to Include in Study Write-Ups
Box 8.3
How to Organize and Report Findings From Mixed-Method Studies
Box 8.4
Does Your Study Matter?
List of Case Studies
Case study 1
: Prevent: Human— Animal Exposure Study
Case study 2
: Engaging Male Partners in Women's Microbicide Use
Case study 3
: LinCS 2 Durham: Linking Communities and Scientists to Durham HIV Prevention
Case study 4
: Sustained Acceptability of Vaginal Microbicides
Case study 5
: Adolescent Women and Microbicide Trials: Assessing Challenges and Opportunities to Their Participation
Case study 6
: A Field Assessment of Adoption of Improved Cook Stove Practices: Focus on Structural Drivers
Case study 7
: Exploring Gender-Based Violence Among Men Who Have Sex with Men, Male Sex Workers, and Transgender Communities
Case study 8
: Sociobehavioral Research and Community Planning to Develop Site-Specific Plans for PrEP Rollout
Case study 9
: Evaluation of Malawi Male Motivator Intervention
Case study 10
: Reasons for Contraceptive Nonuse in Rwanda
Case study 11
: Personal Involvement of Young People in HIV Prevention Campaign Messages: The Role of Message Format, Culture, and Gender
Case study 12
: Voluntary Medical Male Circumcision in Kenya
Case study 13
: Alive & Thrive
Case study 14
: Communicating About Microbicides with Women in Mind
Foreword
For the past 10 years, I have taught an introductory course to master of public health (MPH) students using the first edition of Qualitative Methods in Public Health: A Field Guide for Applied Research (Ulin, Robinson, and Tolley, 2005). It has been an invaluable guide for students eager to understand how and why things work the way they do. The new edition continues that approach. It gives students a solid grounding in the methods of inquiry into the anatomy of a public health problem, teaching them to explore beneath the surface and discover why a problem exists as well as what the practitioner can do to address the problem.
Now in this new edition, examples have been updated and broadened to speak to greater diversity in the public health field. We see in the new material how the field is growing and how research methods have kept pace with new concepts and challenges. Qualitative research methods have found a footing in applied public health, with funding agencies now expecting to see many proposals incorporate a qualitative component in the development, implementation, or evaluation of public health interventions. The second edition takes the reader beyond evaluation of public health interventions and goes directly to research for change. Inequities in power and privilege must be addressed by actively seeking participation of neglected voices, such as women and minorities. Vivid illustrations show how research participants become potential change agents if they have been included in the conduct of the research. This is a bold new approach accompanied by research techniques for making it happen, including more emphasis on the value of mixed methods and on participatory design in which community members actually become partners in the research process.
Readers inexperienced in qualitative research will welcome the clear steps outlined in the chapter on methods, expanded in this edition. They will also discover the utility of mobile devices such as tablets for data collection and consider greater linkages between individual, organizational, and institutional behavior as well as more ambitious goals related to health systems strengthening, health security, human rights, and health equity. The new edition also places more emphasis on qualitative analysis software and on writing for journals, a discussion that seasoned researchers as well as students will find useful.
Given greater recognition today of what qualitative research methods can do to help us understand and solve public health challenges, this book will have a wide audience. Examples in the text cut across problems encountered in public health, community medicine, and social science practice in many parts of the world. Common to all of these is the need for practical, down-to-earth advice on how to apply the methods of qualitative research to real-world settings. Numerous case studies and examples throughout the text and in the appendices provide practical guidance on many aspects of research that conventional text books often neglect, such as developing consent forms, managing budgets, designing interview guides, working with field assistants, and training data collectors.
Taken as a whole, the book represents an accumulation of experience and guidance from researchers who have been using these methods in applied public health work in global and domestic settings for many years. They share their wisdom and insight with readers, helping both to raise excitement about the possibilities these methods offer, and to reassure new researchers who may be considering qualitative methods for the first time.
Suzanne Maman, MHS, PhDUniversity of North Carolina at Chapel Hill
Reference
Ulin, P. R., Robinson, E. T., & Tolley, E. E. (2005). Qualitative Methods in Public Health: A Field Guide for Applied Research. 1st ed. San Francisco, CA: Jossey-Bass.
Acknowledgments
Many individuals had a hand in bringing this second edition of Qualitative Methods in Public Health from plan to press.
There is also history to acknowledge, for a second edition cannot happen without a first edition. We reiterate our thanks to those who helped make that first edition a reality: those at the U.S. Agency for International Development (USAID), who provided both financial support and substantive guidance on the content of the guide, especially Sarah Harbison and the late Erin T. McNeill. We also thank other individuals at FHI 360 (then Family Health International)—particularly Cynthia Woodsong, as well as colleagues at the World Health Organization, the Population Council, and organizations beyond who contributed their assistance, insight, materials, and support. FHI 360 senior management and Cynthia Geary, formerly of FHI 360, saw us through both editions of this book; to them we are further indebted.
We also acknowledge the many program and research staff members at FHI 360 who have shared research materials and stories about what has worked well and not so well when conducting qualitative research in the field. In particular, we offer special thanks to Kathleen MacQueen for contributing the content on qualitative data analysis software. We also thank the contributors of the case studies, a new feature of this second edition: Jean Baker, Aurelie Brunie, Christine Demmelmaier, Natalie Eley, Emily Evens, Cindy Geary, Nemat Hajeebhoy, Michele Lanham, Kathleen MacQueen, Dominick Shattuck, Rose Wilcher, Christina Wong, and Susan Zimicki. Many thanks also to Paul Feldblum, Michele Lanham, Marguerite Marlow, Emily Namey, the Palladium Group, Sonke Gender Justice, and Christina Wong for their contributions to the appendices. We also thank Denise Todloski at the MEASURE Evaluation project at the University of North Carolina at Chapel Hill for designing many of the graphics in this edition.
We owe a debt of gratitude to Allison Pack, Frances McVay, Seth Zisette, and Amy Mills for assisting us with the complex task of attending to the completeness, accuracy, and organization of the references. As for reviewers both known to us (e.g., Marga Eichleay and Allison Pack for Chapter 6) and anonymous, their feedback has helped us to rethink, reword, and reorganize each of the chapters for the betterment of the entire book. And of course, without the support and excellence of Seth Schwartz, Melinda Noack, and Maria Sunny of Wiley, our collective efforts would never have made it to print.
Last, we thank our families for serving as sounding boards and comic relief throughout the process: Mark, Elise, and Kyle Healy; Don and Marjorie Ulin; Solana Mack and Zorro; and Alan Dehmer.
About the Authors
Elizabeth (Betsy) E. Tolley is a senior scientist and Director of the Social and Behavioral Health Sciences division of FHI 360. Since joining Family Health International (now FHI 360) in 1994, Betsy has used qualitative and mixed-methods research to examine acceptability and use of various sexual health, contraceptive, and reproductive behaviors, including new technologies such as microbicides or development of a longer-acting injectable contraceptive, and existing technologies like implants and intra-uterine devices (IUD). An important focus of recent research has been on microbicide acceptability, including identification and measurement of factors that contribute to initiation and sustained use of microbicides in various populations, from Tanzanian adolescents to married women in India or female sex workers in Benin. For example, she conducted mixed-method research in parallel to a phase two microbicide safety trial to first develop scales (e.g., HIV risk perception, couple sexual communication, acceptability of product attributes) and then longitudinally assess their influence on consistent use. More recently, she applied her understanding of how social and sexual contexts shape acceptability in order to develop and test messages and materials for potential microbicide introduction initiatives in Kenya. Other research topics have included assessment of infant feeding practices, as well as adolescent abortion. Betsy brings to FHI experience in the training and use of qualitative research methods, and she is especially interested in exploring ways to make qualitative analysis more systematic and rigorous and to make qualitative and quantitative approaches more compatible. She has a PhD in health behavior from the Gillings School of Public Health, University of North Carolina at Chapel Hill, and an MA in international development from the Nitze School of International Studies, The Johns Hopkins University. Betsy has over 25 years of experience living and working in developing countries, including various countries in West and North Africa, eastern Africa, and India.
Priscilla R. Ulin is retired from Family Health International (now FHI 360), where she was senior research scientist in the Social and Behavioral Sciences division and, through her work in the early days of the AIDS epidemic, she helped establish the organization's qualitative research program. Trained in quantitative social research, she discovered the power of qualitative methods while studying maternal and child health decision making in Botswana in the early 1970s. From then on in her professional career, she combined quantitative and qualitative techniques in research, teaching, and technical assistance in sexual, reproductive, and maternal and child heath in the United States and developing countries. As a medical sociologist, she focused primarily on social change and utilization of health care systems, with an emphasis on the influence of family and community in sexual and reproductive health decision making, and on community participation in research. Dr. Ulin worked in Haiti under the auspices of FHI's USAID-funded AIDSTECH Project, where she pioneered the use of qualitative methods to explore women's sense of vulnerability in the AIDS epidemic. She was deputy director of FHI's Women's Studies Project, a five-year, multinational program of social and behavioral science research, both qualitative and quantitative, on the consequences of family planning for women's lives. She has directed research in sub-Saharan Africa on women's strategies to control their fertility, on the impact of family planning on women's participation in economic development, and on the influence of family on contraceptive decisions. Dr. Ulin received a master's degree in nursing from Yale University and a PhD in sociology from the University of Massachusetts-Amherst.
Natasha Mack is a researcher in the Social and Behavioral Health Sciences division at FHI 360. Originally trained as a linguistic and cultural anthropologist, she has 15 years of experience in qualitative research, as well as scientific writing and editing. Since joining Family Health International (now FHI 360) in 2004, she has conducted qualitative studies in HIV prevention and other public health areas, including studies on the female condom, pre-exposure prophylaxis for HIV prevention, translation issues in informed consent documents, and most recently infant and young child feeding practices. Her work has included sociobehavioral research components of clinical trials as well as standalone qualitative studies in sub-Saharan Africa and Latin America. Writing has been the mainstay of her tenure at FHI 360. This has included a field manual of qualitative methods, funding proposals, research protocols, FAQs and informational briefs, standard operating procedures, executive summaries, presentations, book chapters, and write-up of study results in final reports and peer-reviewed publications. She has also mentored staff in writing peer-reviewed articles. Dr. Mack speaks French and Spanish and has experience in French- and Spanish-to-English translation. She holds a BA (1993) in comparative area studies and Spanish from Duke University. She earned her MA (1997) and PhD (2004) in linguistic and cultural anthropology from the University of Arizona in Tucson.
Elizabeth T. Robinson is the senior advisor for communications at the University of North Carolina at Chapel Hill's $180 million MEASURE Evaluation project, funded by USAID and PEPFAR. She is a communications professional with more than 25 years of experience managing strategic communication, research dissemination, and knowledge management programs for international public health organizations. Prior to joining UNC, Ms. Robinson served as director for knowledge management for the Health Policy Project at Futures Group in Washington, DC, and she previously held several senior-level communication positions at Family Health International (now FHI 360), including director of information programs. Her work experience includes management of large editorial departments, multilingual web development, and writing on topics ranging from Ebola and health systems strengthening to HIV and gender. She has taught scientific paper writing to researchers at the National Institutes of Health, the Pasteur Institute, medical schools, and nongovernmental organizations, and she has worked as a consultant for the Johns Hopkins Bloomberg School of Public Health, the World Health Organization, the University of the Witwatersrand, and elsewhere. She is lead author of the Communications Handbook for Clinical Trials: Strategies, Tips, and Tools to Manage Controversy, Convey Your Message, and Disseminate Results; she was the principal communications advisor to the CAPRISA 004 microbicide trial; and she is the author of several qualitative studies on health communications. Ms. Robinson has devoted much of her professional life to providing technical assistance in communications to health organizations, research institutions, and sectoral ministries in Africa, Asia, and Latin America. Early in her career, she worked as a journalist in metropolitan New York; Washington, DC; North Africa; and Francophone West Africa. Ms. Robinson received a master's degree from the Columbia University Graduate School of Journalism and held a fellowship in the Columbia University School of International and Public Affairs.
Stacey M. Succop is a research associate in the Scientific Affairs department at FHI 360. Ms. Succop has been working in global health and development since 2003, and she joined FHI 360 in 2007. While at FHI 360, Ms. Succop spent more than six years working in the social and behavioral health sciences division, building her experience in study management and logistics, quantitative and qualitative data analysis, research proposal and protocol development, study team training, and scientific writing. She also facilitated relationships and communications for large, multicountry teams and was responsible for developing, coordinating, and monitoring work plans, timelines, and budgets for several simultaneous studies and projects. She worked on research studies and projects covering a wide variety of topics such as HIV prevention, mobile health interventions, family planning, and reproductive health, all in global settings. Currently, Ms. Succop serves as a scientific and technical reviewer for health, population, and nutrition-related protocols developed by staff across the organization. She provides guidance and technical support to research teams related to study design, analysis, and implementation. Ms. Succop holds a BA from Duke University; a master's degree in public health (MPH) in health behavior and health education from the University of North Carolina at Chapel Hill, Gillings School of Public Health, with a certificate in global health and a project management professional (PMP) certification.
Chapter 1Invitation to Explore
Objectives:
To introduce researchers to qualitative methods in public health research, including those whose training and experience may be predominantly in quantitative methods
To describe the basic characteristics of a qualitative research approach
To show how qualitative methods can shed new light on complex questions in public health
To highlight the aspects of qualitative research methodology presented in this book, including content new to this second edition
WHY DO SOME PROGRAMS succeed and others fail? Why are screening programs underused? Why does chronic disease go untreated? Why do countless couples know how to protect themselves from sexually transmitted infection but do not do so? How does a community mobilize itself to solve a persistent health problem? Questions like these may be all too familiar to readers of this field guide—public health practitioners, researchers, and program planners, many of whom have worked for years to protect health and prevent disease in highly vulnerable populations.
Advances in the biomedical and population sciences have brought the means to better health within reach of people around the world. Yet, evidence of escalating disease and inadequate health systems and resources in many countries tell us that there is still much we do not know. How do women and men understand and actually use the technical information they receive to make critical decisions that affect their lives and their children's lives? By opening windows on cultural understandings of health and disease, methods of qualitative research can help us comprehend some of these old problems in new ways.
Our Purpose
The purpose of this book is to make the methods of qualitative science more accessible to researchers and practitioners challenged by problems that affect the public's health. Qualitative design can help us understand the underlying behaviors, attitudes, and perceptions that determine health outcomes; it can identify the social, programmatic, and structural impediments to use of existing services; and it can shed light on how to design new development interventions so they align with the socioeconomic realities of their intended beneficiaries and therefore have a greater potential for success.
We write not only for the qualitative researcher but also for applied social scientists, epidemiologists, health providers, health educators, program managers, and others whose training and experience may be predominantly in quantitative methods. Our readers will be students as well as professionals looking for ways to probe more deeply the whys and hows of questions they may partially have answered in terms of how much and how many. They will want to know what qualitative methods can offer to improve their practice or strengthen their research findings. And many of our readers will be training others to ask the same kinds of questions, to listen, and to observe.
Numerous disciplines have contributed to the phenomenal growth of public health research and practice. Sociology, anthropology, psychology, economics, demography, environmental science, medical geography, medicine, and nursing, among others, have brought their unique perspectives and methods to a multidisciplinary understanding of health and wellness. Parallel advances in these disciplines have resulted in different ways of conceptualizing and addressing issues as diverse as health decision making, health promotion, health systems strengthening, child survival, compliance, substance abuse, adolescent sexuality, domestic violence, and gender relations. Similar progress in service delivery research and evaluation has given us a broader understanding of providers' knowledge and values, client–provider communication, and issues related to the accessibility and quality of health care for populations at risk.
Much of this work has focused on objective questions, such as numbers of births, patterns of illegal drug use, trends in disease prevalence, and numerous factors that predict health behavioral outcomes. Research designs traditionally have been quantitative, describing measurable phenomena, projecting trends, and sometimes discovering causal relationships. Psychological research in health behavior has developed primarily from a quantitative perspective, contributing useful rating scales and behavioral indicators, along with case study methods and tools for observation. Anthropologists and qualitative sociologists have approached some of the same problems from different perspectives, focusing on cultural norms and relationships that influence how people interact and act on everyday experiences (Bernard, 1995; Knodel, 1997). Their methods rely primarily on techniques of observation, participation, guided discussion, in-depth interviewing, life histories, and secondary analysis of documentary data. Emerging methods increasingly used in qualitative research include network analysis and geo-health mapping, using innovative technologies such as data visualization applications and mobile data collection tools.
To conduct rigorous research, investigators must use an appropriate study design, data collection methods, and analytic procedures. Yet there is much overlap among different disciplinary approaches. Quantitative researchers at times use qualitative methods to guide a sampling design or to develop a sensitive data collection tool. Anthropologists and qualitative sociologists turn to quantitative methods when they want to describe a population or measure some tendency they may have observed qualitatively. Quantitative research with representative samples can produce hard, factual, reliable outcome data that usually are generalizable to wider populations (Steckler, McLeroy, Goodman, Bird, & McCormick, 1992). But most quantitative studies lack contextual detail and reflect a limited range of responses (Carey, 1993). On the other hand, qualitative methods elicit rich, contextual data, but their small samples and flexible design usually are not appropriate if the study objective is to describe larger populations with statistical accuracy (Patton, 2002). As a result, researchers have increasingly adopted creative new ways to combine techniques in a research design (Creswell, Klassen, Plano Clark, & Smith, 2011; Teddlie & Tashakkori, 2009), letting the strengths of one method compensate for the limitations of another to yield a more powerful methodology.
We have written this guide not to promote one methodology over another, but because many quantitatively trained health professionals, policymakers, and researchers are looking for ways to expand their methodological options with new tools for answering difficult questions.
In searching the literature on qualitative research, we found it divided between manuals that summarize specific techniques for designing and conducting health-related studies (Campbell, 1999; Hudelson, 1994; Yoddumnern, Mahidon, & Sangkhom, 1993) and more comprehensive texts for general academic audiences (Denzin & Lincoln, 2005, 2011; Guest, Namey, & Mitchell, 2012; Patton, 2002; Rossman & Rallis, 1998). Missing from most manuals was a theoretical basis for qualitative decisions, and few texts included strategies to address practical health research issues and problems that arise in the field. Nor did we find clear guidelines for dealing with the large volume of transcripts that qualitative data collection on sensitive topics often generates. Another gap in the literature was the lack of direction for writing and disseminating qualitative results. Our intent, therefore, is to show first how qualitative methods can shed new light on perplexing questions and, second, to provide basic skills to design, conduct, and disseminate the research.
This volume presents practical strategies and methods for using qualitative research, along with the basic logic and rationale for qualitative research decisions. The guide makes researchers aware of the complexities, advantages, and limitations of qualitative research. Its eight chapters cover a wide range of topics and guide readers through every phase of research—from defining the language and logic of qualitative research, to study design, to the collection, analysis, interpretation, reporting, and dissemination of data.
What Is Qualitative Research?
A challenge to the author of any book on qualitative research is to answer the common sense question: What is it? Although there is no short, comprehensive definition, the unique organizing framework is a theoretical and methodological focus on complex relations between (1) personal and social meanings, (2) individual and cultural practices, and (3) the material environment or context. Similarly, there is no universal blueprint for doing qualitative research, but some basic concepts and principles, described next and summarized in Box 1.1, are common in most qualitative research approaches.
Box 1.1: Characteristics of Qualitative Research
Explores and discovers
Seeks depth of understanding
Views social phenomena holistically
Provides insight into the meanings of decisions and actions
Asks why, how, and under what circumstance things occur
Uses interpretive and other open-ended methods
Is iterative rather than fixed
Is emergent rather than prestructured
Involves respondents as active participants rather than as subjects
Defines the investigator as an instrument in the research process
Qualitative research is systematic discovery.
Its purpose is to generate knowledge of social events and processes by understanding what they mean to people, exploring and documenting how people interact with each other and how they interpret and interact with the world around them. It also seeks to elucidate patterns of shared understanding and variability in those patterns.
Qualitative researchers value natural settings where the researcher can better understand people's lived experiences.
The natural context of people's lives is a critical component of qualitative design because it influences the perspectives, experiences, and actions of participants in the study. It is the interpersonal and sociocultural fabric that shapes meanings and actions.
Many problems central to public health research and practice are deeply embedded in their cultural contexts. People in communities confront decisions and challenges that are conditioned by membership in multiple social groups: whether to vaccinate children, how to prevent obesity, where to go for help in times of illness, and how to give young people the skills and confidence they will need for healthy adulthood. Contradictions and competing priorities can make many seemingly commonplace decisions difficult: Spend money on prescription drugs, or save for retirement? Protect oneself from sexually transmitted infection and risk losing the attention and economic support of a sexual partner, or accept the risk of disease? Running through the fabric of economic, sexual, and reproductive lives are the pervasive influences of gender and power, themes that resonate in the voices of the women and men in our research.
Researchers express qualitative data in participants' words, in images, and sometimes in numbers.
Language, both verbal and nonverbal, has symbolic meaning; an expression may mean one thing to the study participant and a different thing to the interviewer. Qualitative researchers listen carefully to language as participants tell about their experiences without the constraints of externally imposed structure. When we refer to raw data as narrative, we mean participants relating their ideas and experiences in ways that can offer insight into important research concepts and questions.
The fact that people differ in the ways they interpret—and consequently act on—ordinary situations has profound implications for health research. If it is true that what people define as real is real in its consequences (Thomas & Thomas, 1928), then applied behavioral research in public health must have the capacity to uncover multiple perspectives and understand their implications for health decision making. Qualitative researchers have taken this charge seriously, with the result that we now have at our disposal powerful techniques for “hearing data” (Rubin & Rubin, 1995, p. 12), that is, listening to what people are saying about their own lives in their own words.
The qualitative research process is flexible, emergent, and iterative.
The study design is never wholly fixed, but enables an interplay between data collection and discovery. Qualitative studies usually include an iterative design, meaning that findings emerge continuously. The investigator is always in touch with the research process, observing how participants respond to the topic and examining data for fresh insights that might lead to altering a technique, modifying questions, or changing direction to pursue new leads. Analysis does not wait until all the data are collected; it begins in the field.
Reflexivity—the researcher's critical self-awareness—is a vital process of questioning and observing oneself while at the same time listening to and observing the participant.
With their emphasis on egalitarian relationships, feminist and transformative methodologies have contributed greatly to this point. In contrast to the detachment required in many quantitative studies, the observer is a vital component of the qualitative research process in two ways. First, the researcher is in partnership with the participant, working together to explore themes and find answers. Second, he or she is also a key research instrument, not only recording information but at the same time influencing how it is elicited. Self-examination, documented with other observations in the field notes, is part of the iterative process of interpretation and revision that moves the data collection toward its goal.
Qualitative researchers know that there are always at least two key players: the participant who contributes the information and the researcher who, as learner and co-interpreter, guides the process toward the understanding that both seek to articulate. Together they form a partnership for exploring different social understandings of reality. Creating a qualitative research partnership requires a high level of skill. It also carries with it profound ethical obligations because the relationship is based on trust and mutual understanding of a common goal.
Quantitative or Qualitative?
What is social reality, and how do we explain it? The question has stirred debate and polarized social science research between quantitative and qualitative methods. The issue of whether a given approach is appropriate centers on “the capacity of the data, as collected by one method or the other, to describe, understand, and explain social phenomena” (Pedersen, 1992, p. 43). Depending on their academic training and theoretical orientation, researchers often have strong opinions about the relative merits of qualitative and quantitative approaches (Guest, 2013). Theoretical purists argue that because each methodology reflects a different understanding of research, human behavior, and the nature of social life, the two are incompatible (Greenhalgh, 1997). A purist would choose one or the other approach on the principle that mixing quantitative and qualitative methods violates the assumptions on which either framework is constructed (Carey, 1993; Patton, 1990). The debate between those who espouse use of either particular approach revolves around fundamental questions such as, “what is health and disease, who decides what are important research questions, and whose ‘truth’ is the ‘real truth’?” (Meetoo & Temple 2003, p. 6).
Our position, like that of many quantitative and qualitative researchers today, chooses pragmatism over “one-sided paradigm allegiance” (Patton, 1990, p. 38). Our purpose in presenting more than one theoretical framework is to help readers understand similarities and differences, strengths and limitations, and the contribution that each can make to applied health research. The methods that emerge from these frameworks “offer a distinct set of strengths and limitations that are markedly different but potentially complementary when combined in a mixed-method research design” (Wolff, Knodel, & Sittitrai, 1991, p. 2).
Throughout this book, we advocate methodological appropriateness—using theory and related methods to make reasoned decisions “appropriate to the purpose of the study, the questions being investigated, and the resources available” (Patton, 1990, p. 39).
Application of Research to Action
We have chosen to focus on applied research because it informs action and enhances decision making on practical issues, unlike basic research, which is conducted to generate theory and produces knowledge for its own end. Although applied research can add immeasurably to our understanding of human, institutional, and systems behavior, its outcomes are “judged by their effectiveness in helping policymakers, practitioners, and the participants themselves make decisions and act to improve the human condition” (Rossman & Rallis, 1998, p. 6). Most well-designed qualitative studies have elements of both the basic and the applied, because rigorous applied research has a theoretical base and scholars ground their theory in concrete findings. Unfortunately, however, too many examples of hastily constructed qualitative research attempt to apply faulty findings to policy or program issues. Such studies often have inadequate theoretical bases or use data collection techniques that are inappropriate to the purpose of the research. These misguided efforts do not constitute science and seldom contribute significantly to solutions to problems.
At least three important developments are fueling the demand for qualitative expertise in both domestic and international health arenas:
Advances in cross-cultural understanding of health and health-related behavior
Global health patterns
Increased awareness of issues in human rights and health equity, particularly implications for access to health care services by the underserved, including the poor and ethnic and sexual minorities
Advances in Cross-Cultural Understanding of Health and Health-Related Behavior
Sophisticated quantitative methods have produced an extensive base of knowledge for understanding such phenomena as population growth, disease patterns, and many aspects of human behavior that are determinants of health and sickness. But each new finding leads to more questions and new research problems that often require a different approach to data collection and analysis. For example, knowing the number of tuberculosis cases in a given region leads us to ask why infection is still high in some populations. Or with the wide availability of primary health care services, we must ask why so many potentially serious diseases continue to go undetected in their early stages. Qualitative methods are adding a new dimension to the ongoing search for answers to these and other complex questions.
Designs for quantitative surveys are increasingly incorporating qualitative techniques in an effort to improve the validity of interview tools through better understanding of the language and perspectives of study populations (see Case Study 1 in Appendix 1). Hearing participants' customary language for sexual issues helps the survey researcher compose standardized items in familiar words or prestructured response categories from actual experience. Program planners too are finding that participation of affected groups in collecting qualitative data and analyzing local problems leads to more relevant programs and a greater sense of community ownership. In eastern North Carolina, for example, a study to investigate the potential impact of industrial swine operations on decreased health and quality of life employed trained interviewers in a household survey of three rural communities. A community resident accompanied each interviewer to explain the purpose and importance of the survey, resulting in a participation rate of 86% (Wing & Wolf, 2000).
At the same time, technological innovations, such as analytic tools based on geographic information systems (GIS), are fueling rapid changes in the range of perspectives that qualitative research can explore. Use of new information, communication, and technology tools for data collection, such as mobile phones and tablets, are fueling creative approaches to implementing study designs, such as participatory action research, that “prioritize flexibility and accessibility in the processes and products of our inquiry” (Cope & Elwood, 2009, p. 171).
Global Health Patterns
Demographic and health statistics speak to the urgent need for solutions to public health problems everywhere. Growing health disparities between rich and poor countries, as well as between urban and rural areas of many countries, highlight different research needs. In an Ebola outbreak, for example, the strength or weakness of a country's health system and deeply rooted cultural practices for burial of the dead, if not understood and addressed, can contribute to a pandemic, endangering global health security (West African Health Organization [WAHO], 2015). In the United States, heart disease, cancer, respiratory diseases, and stroke account for more than half of total annual deaths (Hoyert & Xu, 2012), and many instances of these health issues are related to tobacco use, poor diet, physical inactivity, and alcohol consumption. In the poorest areas of the world, preventable and treatable diseases, such as diarrhea, measles, and malaria, take a heavy toll on human life. In Africa alone, more than 2.3 million people die from vaccine-preventable diseases annually (Carr, 2004). Complications of pregnancy, childbirth, and unsafe abortion claim the lives of over 500,000 women every year, 99% of them in developing countries (World Health Organization [WHO], 2014). Globally, 15% of all women living with HIV (aged 15 years and older) are 15 to 24 years old; of these, 80% live in sub-Saharan. (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2014). Moreover, many health experts are only just beginning to acknowledge the full impact of social problems such as gender-based violence, the feminization of poverty, homelessness and mental illness, economic crises, persistent regional conflict, and refugee resettlement—all play out in a climate of increasing globalization and overburdened resources.
This book illustrates the principles of qualitative research in the context of global health, with reference to social and behavioral determinants of many preventable health problems. Qualitative research is not a solution but rather a route to better understanding of the human condition, with the hope of contributing to more rational decision making for improved health program effectiveness and impact. Given the magnitude of the problems we face, we must use all the tools at our disposal, and use them well.
Increased Awareness of Issues in Human Rights
A growing awareness of the impact of social environment on health has focused attention on the interplay among population and development, human rights, and gender. If we hope to address pressing needs for improved health and social development, we urgently need better understanding of the complexities of human and institutional behavior. The desire to probe interrelationships among, for example, health decisions, human rights, gender equity, equality, and empowerment calls for new ways to address old, intractable questions. Investigators from the fields of women's studies and applied disciplines in the social sciences continue to search for better understanding of key developmental processes such as gender socialization and role awareness, raising new questions that invite a more qualitative approach to research.
Concern for the status of women is a critical element in development policy, but human rights and the ethics of inclusion add another dimension. We are seeing a gradual shift of priorities toward new goals for community participation, human rights advocacy, gender equity, and health equity broadly defined (United Nations Human Rights, 2008). These trends have strengthened research outcomes by influencing how research is conceptualized and conducted. Our research questions are more likely now to include attention to gender relations in health decision making and to status and power as significant factors in the study of health service delivery. Qualitative methods enable researchers to explore more fully the nature and consequences of gender identities and relations not only in reproductive health but also, for example, in access to and use of malaria prevention and treatment services (Kenya Ministry of Health, 2015). As they become more aware of the powerful role of status in everyday life, researchers themselves are increasingly adopting participatory, transformative approaches to research that are consistent with qualitative work. This shift is creating new collaborative relationships with study participants and heightened awareness of the researcher's ethical responsibility in the data collection partnership.
Getting Started
Like the first edition, this second edition takes you step-by-step through the qualitative research process from its theoretical base to its application in public health problems, to dissemination of findings for program and policy change. Key elements in the process are interaction and interpretation. By interaction, we mean broadly the art and science of asking, observing, listening, reflecting, and probing—always with the purpose of engaging people in meaningful dialogue. We advocate qualitative techniques, independent of or in association with quantitative methodology, as a way of discovering how people act and interact in the familiar contexts of their lives. Our purpose is to share what we have learned with other researchers who are similarly committed to systematic analysis to inform policy and program development for healthier and more empowered populations.
The chapters that follow build the qualitative process: understanding, designing, implementing, and using methods to answer questions and solve problems that challenge workers in public health.
Chapter 2, The Language and Logic of Qualitative Research, begins with a brief overview of the theoretical basis for qualitative research, emphasizing the practical application of theory to research design and analysis. To help the reader locate qualitative research in the theoretical universe, we review three important paradigms, or theoretical frameworks, that have guided methodological decisions in social and behavioral health research. We emphasize the complementarity of these frameworks and the added value of linking them in well-coordinated designs to solve complex problems. Chapter 2 also presents examples of substantive theories and conceptual models that public health researchers may use to guide their research designs or synthesize study findings. We conclude Chapter 2 with a discussion of standards for judging the scientific rigor of qualitative research. We maintain that different assumptions and purposes make the criteria for evaluating quality in quantitative and qualitative studies analogous but not interchangeable.
In Chapter 3, Designing the Study, we present and discuss important design questions in a sequence that follows a typical research proposal. Basic steps move from defining the area of inquiry and the purpose and problem of the research to analyzing, writing, and disseminating the findings. We also discuss conceptual frameworks that link concepts and relationships to qualitative data collection strategies. We then review aspects of informed consent that are particularly relevant to qualitative studies, including the ethical responsibility of the researcher in an open-ended interview or discussion. To underscore the point that combining qualitative and quantitative methods can increase the power of the design and result in a more comprehensive understanding of the topic of study, we present practical strategies and resources for mixed-method design.
Chapter 4, Collecting Qualitative Data: The Science and the Art, describes the principal methods of data collection. We identify three fundamental methods—observation, in-depth interviewing, and focus group discussion. Observation is further divided into nonreactive (including documentary research) and participant observation. Techniques of in-depth interviewing and focus group discussion are presented in detail, along with participatory research methods and other selected structured qualitative approaches: freelisting and pile sorts, photo narrative, storytelling, network analysis, and body mapping. We recommend a semi-structured approach to data collection and discuss the construction and use of topic guides.
In Chapter 5, Logistics in the Field, we focus on implementation. This chapter contains practical recommendations for introducing a study; building a research team; working with stakeholders and policymakers; selecting and training data collectors; developing field materials; and recording, transcribing, and translating data.
Chapter 6, Qualitative Data Analysis, is a comprehensive overview in which the reader learns how to process and interpret text by working through five interrelated steps. We draw on a single case study to provide concrete examples of how to read, code, display, reduce, and interpret qualitative data. Included in this discussion are guidelines for analysis of data in mixed-method studies. We then detail the concept of rigor in qualitative studies, showing how qualitative concepts analogous to validity and reliability can be used to judge the trustworthiness of the findings. In this chapter, we also emphasize the importance of selecting appropriate software for computer text analysis, and we summarize some of the distinguishing features of several programs in common use.
Chapter 7, Disseminating Qualitative Research, outlines ways to effectively disseminate and promote the use of results. We suggest some possible outcome indicators for dissemination and use of study findings and challenge researchers to reconsider their roles in planning and implementing dissemination.
Chapter 8, Putting It Into Words: Reporting Qualitative Research Results in Scientific Journals and Reports, discusses the steps in writing up qualitative study findings. These steps incorporate ethical norms that govern how we present results, integrate thematic ideas into a meaningful narrative, determine our audiences, and select a presentation format that is both appropriate to the study methods and relevant to potential readers. The chapter offers practical advice on how to organize qualitative findings in articles for peer-reviewed journals as well as written reports, how to report combined qualitative and quantitative results, and considerations for enhancing the credibility and communicability of qualitative writing. We include criteria that external reviewers commonly use to evaluate journal manuscripts, discuss authorship issues, and provide suggestions for the submission process.
