Qualitative methods in public health

METTE SAGBAKKEN

DEPARTMENT OF GENERAL PRACTICE AND COMMUNITY MEDICINE

INSTITUTE OF HEALTH AND SOCIETY

Qualitative methods in public health

"The cure of many diseases remains unknown to the physicians of Hellos (Greece) because they do not study the whole person." ~ Socrates, (470-399 BC)

"The control of many diseases remains difficult because health professionals and policy makers do not study the whole picture” ~ Sagbakken, (1966- AC)

Qualitative versus quantitative methods

Prior to establishment of disciplines as anthropology, epidemiology – health projects often combined methods

Panum: investigated measles outbreak in the Faroe Islands in 1846 – combined observations and syrveys

Virchow: investigated typhus epidemic in 1848 – clinical, pathological, epidemiological, anthropological findings

Documented concrete links between social conditions and diseases

Trostle J. (2005). Epidemiology and culture. Cambridge University Press.


After discovery of bacteria specific to infectious diseases (1870s-1880s) the germ theory of disease becomes dominant

Development of laboratory disciplines as bacteriology, virology – less focus on social, economic, and cultural factors in disease control

Growth of disciplines, growing emphasis on quantitative research and dominance of medical profession in public

health

Separation of approaches to disease prevention and control

Robert Koch (1843-1910)

Yach. D (1992). The use and value of qualitative methods in health research in developing countries. Soc Sci Med, 4:603-12


“Not everything that can be counted

counts, and not everything that counts can be counted.”

Albert Einstein (1879-1955)

What knowledge ”counts”?

Many tuberculosis (TB) patients do not complete treatment. How many? (quantitative) Why? (qualitative)

Many TB patients use several months to get the right diagnosis. How many (quantitative)? Why? (qualitative)

Predefined categories – a ”shot-gun” method? (Becker)

Strength of qualitative methods – show how a multitude of factors may act as causes

What knowledge ”counts”?

Different methods important – can play complementary roles

Ex: Qualitative methods help explain mortality rates (men, third class passengers) in Titanic by exploring social and cultural rules

Social rule about class implied higher status passengers saved at the expense of lower-status passengers

Cultural rule of lifeboat access caused more men to die (within economic status group)

Trostle J. (2005). Epidemiology and culture. Cambridge University Press.


Which research method? Depends on the question

Quantitative methods: Suitable for questions such as:

”How many…?”, ”How often ...?”, or ”Is X more efficient than Y in treating Z?”

Qualitative methods: Suitable for questions such as: ”How do people perceive…?”, ”What do people do?”,

or ”How do people experience ...?”

Qualitative methods

The aim of qualitative research is not to measure or predict, but to gain new knowledge/understanding of phenomena such as:

Human experience, beliefs, behaviour, interaction

Social practices, systems, cultural norms

Involves collection of data not easily reduced to numbers

Qualitative methods

Humans are contextual beings

Understand the wider context in which peoples’ preferences, beliefs and behavior derive

Understand processes and dynamics of social life

What causes changes in behavior?

Qualitative methods

Impoverishment

Daily clinic attendance –

new costs and burdens

Impoverishment

Exhaustion Hopelessness

New strategies

Treatment interruption

Becoming ill

Loss of job/incomeExpenses

Identify processes

Treatment interruption

Accumulated burdens/costs- tipping point

Qualitative methods..

Allow people to speak in their own voice, rather than conforming to categories and terms imposed by others

Categories often not predefined: the fieldwork informs you of relevant categories (inductive - abductive)

Qualitative methods

Through exploration of meaning new and unexpected categories of meaning and experience can be discovered –

….that did not fit the original puzzle

Qualitative methods

Structural factors

• Loss of income

• Distance to clinic

• Organization of treatment

Socio-cultural factors

• Stigma in community

• Cultural obligations

Individualfactors

• Different explanatory models

• Other obligations

Outcomes may have multiple causes

Important to get an overview over causes – and how they may interrelate

Qualitative methods

By identify processes and multiple causes – create time- and context sensitive approaches to disease prevention and control:

By identifying multiple causes – increase awareness of the need of linking multiple actors/sectors/projects (food programs, labour organizations)

Through a dialogue with those concerned : - discover processes and experiences people go through being ill - identify local barriers and enablers - identify existing or non-existent support structures - help identify mutiple and more sustainable solutions (beyond bio-

med)

Qualitative data collection methods

Data collection methods

Interviews

Individual interviews Semi-structured In-depth

Informal conversations

Group interviewsFocus groups


Individual interviews – advantages Opportunity to probe; explore further Get close to people; establish trust; Beneficial for sensitive issues. Several interviews can be

done.

Individual interviews – challenges Do not discover discrepancy between what people say and

what they do Structured situation – statements decontextualized

Informal conversations – advantages Often takes place in context – talk about what you see/hear People are more relaxed, more spontaneous answers

Informal conversations – challenges Less structured; less focused. Recall bias


Focus groups – advantages Study interaction patterns Identify issues to include in subsequent individual

interviews Validate findings from individual interviewsGenerate new meaning – several minds work togetherMore data in less time

Focus groups – challenges Learn what people say they do, not what they actually doSome may dominate – consensus reached on wrong

premises Less suitable for sensitive topics


Observation Participant or non-participant

“Fieldwork”


Observation – advantagesBehaviour/statements better

understood in light of contextMove beyond the selective perceptions of othersDiscover issues no one has

paid attention to (tacit knowledge)

Learn about issues people are reluctant to talk about

Insight into processes/ chronologies of events

Understand complex topics

Observation - challengesTo what extent, in what

way are you influencing the field?

Is what you ”see” what is really happening?

Should know the local language

Time consuming

Data collection in qualitative methods

Study of texts and documents

Documents, books, articles, reports, advertisements, newspapers, diaries

Adds important contextual information – understanding findings