qualitative research methods public health

The value of qualitative methods to public health research, policy and practice

Affiliations.

• 1 Institute of Mental Health, University of Nottingham Faculty of Medicine and Health Sciences, Triumph Road, Nottingham NG7 2UH, UK.
• 2 The University of Sheffield, Sheffield, UK.
• 3 Sheffield Hallam University, Sheffield, UK.
• PMID: 35362352
• PMCID: PMC9446427
• DOI: 10.1177/17579139221083814

This article reviews the role and use of qualitative methods in public health research.'Signs of quality' are introduced to help guide potential authors to publish their qualitative research in public health journals. We conclude that high-quality qualitative research offers insights that quantitative research cannot. It is time for all public health journals to recognise the value of qualitative research and increase the amount that they publish.

Keywords: public health; publishing; qualitative methods.

Publication types

• Public Health*
• Publishing*
• Qualitative Research

EDITORIAL article

Editorial: qualitative research applied to public health: new topics and insight.

• 1 Department of Nursing, Physiotherapy and Medicine, University of Almería, Almería, Spain
• 2 Ciencias de la salud, Universidad Autónoma de Chile, Santiago, Chile
• 3 Department of Physiotherapy, University of Alcalá, Alcalá de Henares, Madrid, Spain

Editorial on the Research Topic Qualitative research applied to public health: new topics and insight

The concept of public health refers to the science and art of preventing diseases and promoting, protecting, and improving health ( 1 ). The essential functions of public health include monitoring the health of the population, keeping watch on risk factors, guaranteeing access to healthcare services, and promoting research, among others. Although there have been many advances over the years in vaccine development, emergency response, the promotion of sexual and reproductive health, and access to medicine, a single solution has yet to be found which meets the needs of the population in different health systems ( 2 ). Classical epidemiology studies the phenomena of health and disease in the community, considering the population as a group of individuals without considering the many individual and social factors. Qualitative methodology contributes to the study of the determinants of health and disease, healthcare planning, the detection of needs, and the evaluation of interventions from the experiences of individuals and societies ( 3 ). In the face of a unitary, measurable, and external reality to the cognoscente, there is a reality which each person creates within the framework of their culture, tradition, and history. Therefore, the implementation of a dual research perspective in public health must involve quantitative approaches that address the generality of the study problem, but also qualitative ones, which include multiple layers of diversity and the range of lived experiences ( 4 , 5 ). As reflected in our Research Topic, the experiences of patients, professionals, and families are key to understanding public health problems.

Research does not occur isolated from the interests and powers of the academic, scientific, personal, or theoretical field ( 6 ). Together with the technical interest in knowing the reality in order to transform it ( Zang et al. ), practical interest points to the intersubjective understanding of the health-disease process, and emancipatory interest points to actively taking charge of this process. In line with studying the experiences of patients, Wang et al. found specific action plans, medical feedback, and periodic records as facilitators of adherence to lifestyle prescriptions among patients with non-alcoholic fatty liver disease. Bailey-Davis et al. found that obese patients undergoing treatment in primary care expect personalized treatment options and referrals to effective community programmes. Campaña et al. , suggests that being a woman with a low educational background coming from the public health system outside of the capital could contribute to barriers for effective healthcare for lung cancer in Chile . Gabay , proposes that positive experiences in the relationship between the patient and nurse instill hope for being discharged in intensive care units. Experiences of young generations on the social problems of parental care are addressed by Peng et al. , emphasizing that governments should guarantee that adult children receive help to balance their work, life, and parental care responsibilities. Chen et al. found that major epidemics accelerate and promote major social changes, technological development, political, and economic measures. Experiences of members of public health associations in tracking and treating COVID-19 cases in migrants and refugees are studied by Dawson-Hahn et al. . Qualitative research also studies the experiences of evaluating public health intervention programmes, such as the case of Thoumi et al. when addressing health inequalities in Latinx communities in North Carolina; or the perspective of professionals on the barriers, facilitators, and elements for improving the +AGIL Barcelona programme ( Canet-Vélez and Solis-Navarro ). Teaching-learning experiences are also addressed by qualitative research in the different stages. In undergraduate studies, Zhu et al. suggests that a synthesis of knowledge and practice is needed to improve the professional skills of undergraduate nursing students. In postgraduate studies, Sánchez-Muñoz et al. found that the residency period is important in the training and acquisition of skills as a Family and Community Nursing Specialist Nurse in Spain, and improvements are needed to guarantee quality training and more visibility. Myroniuk et al. recommends involving health sciences students in public health programmes aimed at the community. Experiences of public healthcare professionals have also been studied in our Research Topic. Canet-Vélez et al. suggests that legal regulation has provided a security framework for nurse prescribing. However, strategies are needed for its comprehensive development, public acceptance and to give visibility to nurse prescribing at an international level. Along with practical interest, emancipatory interest is key in qualitative research. Researchers analyze public health problems through self-reflection, seeking social transformation, and participant involvement for change. This positioning generates empowerment, leading patients to participate in decision-making and take charge of their own health. Along these lines, Röger-Offergeld et al. studied how the participation of women as co-researchers leads to their social empowerment beyond the results of the research itself. Melhem et al. found that health literacy and empowering survivors of colorectal cancer promotes a more positive experience when interacting with healthcare systems.

Gadamer and Habermas criticize the excessively objectified and decontextualized nature of positivism and instrumental reason in 20 th century philosophy, recognizing the role of the subject in the creation and acquisition of knowledge and understanding ( 7 ). Qualitative research is increasingly common in contemporary health sciences, helping to incorporate the perspectives of the participants (patients, family, professionals, managers, etc.) in the design and development of the research, treating them as equals. Qualitative public health researchers could strengthen dialogue with conventional research paradigms by fostering an understanding of interdependencies ( 8 ). Investigating social determinants and health inequities requires epidemiologists and public health researchers to expand theories, research methodologies, and involve all participants ( 9 , 10 ). The perspective of those who use public health services differs from the professional, clinical or academic perspective ( 11 ). Qualitative research enables an understanding of how people interpret and respond to public health policies, thus weighing the sources of academic and experiential knowledge ( 12 ). The main strength of qualitative research is the in-depth and rich descriptions of data that is studied ( 13 ). For this reason, it is used in global public health when the problems cannot be analyzed from traditional quantitative approaches, when “silenced voices” are not heard, or when sociocultural contexts are key in decision making and problem solving ( 14 ). This contribution, which complements epidemiological research, is key for all knowledge disciplines that develop research on global public health and on all communities in particular.

Author contributions

JG-M: Writing—review & editing. MR-F: Writing—review & editing. IF-M: Writing—review & editing. SN-N: Writing—review & editing. IS: Writing—review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: public health, qualitative research, experiences, nursing research, health sciences research

Citation: Granero-Molina J, Ruiz-Fernández MD, Fernández-Medina IM, Núñez-Nagy S and Suazo Galdames IC (2024) Editorial: Qualitative research applied to public health: new topics and insight. Front. Public Health 12:1371938. doi: 10.3389/fpubh.2024.1371938

Received: 17 January 2024; Accepted: 26 January 2024; Published: 06 February 2024.

Edited and reviewed by: Christiane Stock , Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany

Copyright © 2024 Granero-Molina, Ruiz-Fernández, Fernández-Medina, Núñez-Nagy and Suazo Galdames. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: José Granero-Molina, jgranero@ual.es

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Collecting and Analyzing Qualitative Data

Brent Wolff, Frank Mahoney, Anna Leena Lohiniva, and Melissa Corkum

• Choosing When to Apply Qualitative Methods
• Commonly Used Qualitative Methods in Field Investigations
• Sampling and Recruitment for Qualitative Research
• Managing, Condensing, Displaying, and Interpreting Qualitative Data
• Coding and Analysis Requirements

Qualitative research methods are a key component of field epidemiologic investigations because they can provide insight into the perceptions, values, opinions, and community norms where investigations are being conducted ( 1,2 ). Open-ended inquiry methods, the mainstay of qualitative interview techniques, are essential in formative research for exploring contextual factors and rationales for risk behaviors that do not fit neatly into predefined categories. For example, during the 2014–2015 Ebola virus disease outbreaks in parts of West Africa, understanding the cultural implications of burial practices within different communities was crucial to designing and monitoring interventions for safe burials ( Box 10.1 ). In program evaluations, qualitative methods can assist the investigator in diagnosing what went right or wrong as part of a process evaluation or in troubleshooting why a program might not be working as well as expected. When designing an intervention, qualitative methods can be useful in exploring dimensions of acceptability to increase the chances of intervention acceptance and success. When performed in conjunction with quantitative studies, qualitative methods can help the investigator confirm, challenge, or deepen the validity of conclusions than either component might have yielded alone ( 1,2 ).

Qualitative research was used extensively in response to the Ebola virus disease outbreaks in parts of West Africa to understand burial practices and to design culturally appropriate strategies to ensure safe burials. Qualitative studies were also used to monitor key aspects of the response.

In October 2014, Liberia experienced an abrupt and steady decrease in case counts and deaths in contrast with predicted disease models of an increased case count. At the time, communities were resistant to entering Ebola treatment centers, raising the possibility that patients were not being referred for care and communities might be conducting occult burials.

To assess what was happening at the community level, the Liberian Emergency Operations Center recruited epidemiologists from the US Department of Health and Human Services/Centers for Disease Control and Prevention and the African Union to investigate the problem.

Teams conducted in-depth interviews and focus group discussions with community leaders, local funeral directors, and coffin makers and learned that communities were not conducting occult burials and that the overall number of burials was less than what they had experienced in previous years. Other key findings included the willingness of funeral directors to cooperate with disease response efforts, the need for training of funeral home workers, and considerable community resistance to cremation practices. These findings prompted the Emergency Operations Center to open a burial ground for Ebola decedents, support enhanced testing of burials in the private sector, and train private-sector funeral workers regarding safe burial practices.

Source: Melissa Corkum, personal communication.

Similar to quantitative approaches, qualitative research seeks answers to specific questions by using rigorous approaches to collecting and compiling information and producing findings that can be applicable beyond the study population. The fundamental difference in approaches lies in how they translate real-life complexities of initial observations into units of analysis. Data collected in qualitative studies typically are in the form of text or visual images, which provide rich sources of insight but also tend to be bulky and time-consuming to code and analyze. Practically speaking, qualitative study designs tend to favor small, purposively selected samples ideal for case studies or in-depth analysis ( 1 ). The combination of purposive sampling and open-ended question formats deprive qualitative study designs of the power to quantify and generalize conclusions, one of the key limitations of this approach.

Qualitative scientists might argue, however, that the generalizability and precision possible through probabilistic sampling and categorical outcomes are achieved at the cost of enhanced validity, nuance, and naturalism that less structured approaches offer ( 3 ). Open-ended techniques are particularly useful for understanding subjective meanings and motivations underlying behavior. They enable investigators to be equally adept at exploring factors observed and unobserved, intentions as well as actions, internal meanings as well as external consequences, options considered but not taken, and unmeasurable as well as measurable outcomes. These methods are important when the source of or solution to a public health problem is rooted in local perceptions rather than objectively measurable characteristics selected by outside observers ( 3 ). Ultimately, such approaches have the ability to go beyond quantifying questions of how much or how many to take on questions of how or why from the perspective and in the words of the study subjects themselves ( 1,2 ).

Another key advantage of qualitative methods for field investigations is their flexibility ( 4 ). Qualitative designs not only enable but also encourage flexibility in the content and flow of questions to challenge and probe for deeper meanings or follow new leads if they lead to deeper understanding of an issue (5). It is not uncommon for topic guides to be adjusted in the course of fieldwork to investigate emerging themes relevant to answering the original study question. As discussed herein, qualitative study designs allow flexibility in sample size to accommodate the need for more or fewer interviews among particular groups to determine the root cause of an issue (see the section on Sampling and Recruitment in Qualitative Research). In the context of field investigations, such methods can be extremely useful for investigating complex or fast-moving situations where the dimensions of analysis cannot be fully anticipated.

Ultimately, the decision whether to include qualitative research in a particular field investigation depends mainly on the nature of the research question itself. Certain types of research topics lend themselves more naturally to qualitative rather than other approaches ( Table 10.1 ). These include exploratory investigations when not enough is known about a problem to formulate a hypothesis or develop a fixed set of questions and answer codes. They include research questions where intentions matter as much as actions and “why?” or “why not?” questions matter as much as precise estimation of measured outcomes. Qualitative approaches also work well when contextual influences, subjective meanings, stigma, or strong social desirability biases lower faith in the validity of responses coming from a relatively impersonal survey questionnaire interview.

The availability of personnel with training and experience in qualitative interviewing or observation is critical for obtaining the best quality data but is not absolutely required for rapid assessment in field settings. Qualitative interviewing requires a broader set of skills than survey interviewing. It is not enough to follow a topic guide like a questionnaire, in order, from top to bottom. A qualitative interviewer must exercise judgment to decide when to probe and when to move on, when to encourage, challenge, or follow relevant leads even if they are not written in the topic guide. Ability to engage with informants, connect ideas during the interview, and think on one’s feet are common characteristics of good qualitative interviewers. By far the most important qualification in conducting qualitative fieldwork is a firm grasp of the research objectives; with this qualification, a member of the research team armed with curiosity and a topic guide can learn on the job with successful results.

Semi-Structured Interviews

Semi-structured interviews can be conducted with single participants (in-depth or individual key informants) or with groups (focus group discussions [FGDs] or key informant groups). These interviews follow a suggested topic guide rather than a fixed questionnaire format. Topic guides typically consist of a limited number ( 10– 15 ) of broad, open-ended questions followed by bulleted points to facilitate optional probing. The conversational back-and-forth nature of a semi-structured format puts the researcher and researched (the interview participants) on more equal footing than allowed by more structured formats. Respondents, the term used in the case of quantitative questionnaire interviews, become informants in the case of individual semi-structured in-depth interviews (IDIs) or participants in the case of FGDs. Freedom to probe beyond initial responses enables interviewers to actively engage with the interviewee to seek clarity, openness, and depth by challenging informants to reach below layers of self-presentation and social desirability. In this respect, interviewing is sometimes compared with peeling an onion, with the first version of events accessible to the public, including survey interviewers, and deeper inner layers accessible to those who invest the time and effort to build rapport and gain trust. (The theory of the active interview suggests that all interviews involve staged social encounters where the interviewee is constantly assessing interviewer intentions and adjusting his or her responses accordingly [ 1 ]. Consequently good rapport is important for any type of interview. Survey formats give interviewers less freedom to divert from the preset script of questions and formal probes.)

Individual In-Depth Interviews and Key-Informant Interviews

The most common forms of individual semi-structured interviews are IDIs and key informant interviews (KIIs). IDIs are conducted among informants typically selected for first-hand experience (e.g., service users, participants, survivors) relevant to the research topic. These are typically conducted as one-on-one face-to-face interviews (two-on-one if translators are needed) to maximize rapport-building and confidentiality. KIIs are similar to IDIs but focus on individual persons with special knowledge or influence (e.g., community leaders or health authorities) that give them broader perspective or deeper insight into the topic area ( Box 10.2 ). Whereas IDIs tend to focus on personal experiences, context, meaning, and implications for informants, KIIs tend to steer away from personal questions in favor of expert insights or community perspectives. IDIs enable flexible sampling strategies and represent the interviewing reference standard for confidentiality, rapport, richness, and contextual detail. However, IDIs are time-and labor-intensive to collect and analyze. Because confidentiality is not a concern in KIIs, these interviews might be conducted as individual or group interviews, as required for the topic area.

Focus Group Discussions and Group Key Informant Interviews

FGDs are semi-structured group interviews in which six to eight participants, homogeneous with respect to a shared experience, behavior, or demographic characteristic, are guided through a topic guide by a trained moderator ( 6 ). (Advice on ideal group interview size varies. The principle is to convene a group large enough to foster an open, lively discussion of the topic, and small enough to ensure all participants stay fully engaged in the process.) Over the course of discussion, the moderator is expected to pose questions, foster group participation, and probe for clarity and depth. Long a staple of market research, focus groups have become a widely used social science technique with broad applications in public health, and they are especially popular as a rapid method for assessing community norms and shared perceptions.

Focus groups have certain useful advantages during field investigations. They are highly adaptable, inexpensive to arrange and conduct, and often enjoyable for participants. Group dynamics effectively tap into collective knowledge and experience to serve as a proxy informant for the community as a whole. They are also capable of recreating a microcosm of social norms where social, moral, and emotional dimensions of topics are allowed to emerge. Skilled moderators can also exploit the tendency of small groups to seek consensus to bring out disagreements that the participants will work to resolve in a way that can lead to deeper understanding. There are also limitations on focus group methods. Lack of confidentiality during group interviews means they should not be used to explore personal experiences of a sensitive nature on ethical grounds. Participants may take it on themselves to volunteer such information, but moderators are generally encouraged to steer the conversation back to general observations to avoid putting pressure on other participants to disclose in a similar way. Similarly, FGDs are subject by design to strong social desirability biases. Qualitative study designs using focus groups sometimes add individual interviews precisely to enable participants to describe personal experiences or personal views that would be difficult or inappropriate to share in a group setting. Focus groups run the risk of producing broad but shallow analyses of issues if groups reach comfortable but superficial consensus around complex topics. This weakness can be countered by training moderators to probe effectively and challenge any consensus that sounds too simplistic or contradictory with prior knowledge. However, FGDs are surprisingly robust against the influence of strongly opinionated participants, highly adaptable, and well suited to application in study designs where systematic comparisons across different groups are called for.

Like FGDs, group KIIs rely on positive chemistry and the stimulating effects of group discussion but aim to gather expert knowledge or oversight on a particular topic rather than lived experience of embedded social actors. Group KIIs have no minimum size requirements and can involve as few as two or three participants.

Egypt’s National Infection Prevention and Control (IPC) program undertook qualitative research to gain an understanding of the contextual behaviors and motivations of healthcare workers in complying with IPC guidelines. The study was undertaken to guide the development of effective behavior change interventions in healthcare settings to improve IPC compliance.

Key informant interviews and focus group discussions were conducted in two governorates among cleaning staff, nursing staff, and physicians in different types of healthcare facilities. The findings highlighted social and cultural barriers to IPC compliance, enabling the IPC program to design responses. For example,

• Informants expressed difficulty in complying with IPC measures that forced them to act outside their normal roles in an ingrained hospital culture. Response: Role models and champions were introduced to help catalyze change.
• Informants described fatalistic attitudes that undermined energy and interest in modifying behavior. Response: Accordingly, interventions affirming institutional commitment to change while challenging fatalistic assumptions were developed.
• Informants did not perceive IPC as effective. Response: Trainings were amended to include scientific evidence justifying IPC practices.
• Informants perceived hygiene as something they took pride in and were judged on. Response: Public recognition of optimal IPC practice was introduced to tap into positive social desirability and professional pride in maintaining hygiene in the work environment.

Qualitative research identified sources of resistance to quality clinical practice in Egypt’s healthcare settings and culturally appropriate responses to overcome that resistance.

____________________ Source: Anna Leena Lohiniva, personal communication.

Visualization Methods

Visualization methods have been developed as a way to enhance participation and empower interviewees relative to researchers during group data collection ( 7 ). Visualization methods involve asking participants to engage in collective problem- solving of challenges expressed through group production of maps, diagrams, or other images. For example, participants from the community might be asked to sketch a map of their community and to highlight features of relevance to the research topic (e.g., access to health facilities or sites of risk concentrations). Body diagramming is another visualization tool in which community members are asked to depict how and where a health threat affects the human body as a way of understanding folk conceptions of health, disease, treatment, and prevention. Ensuing debate and dialogue regarding construction of images can be recorded and analyzed in conjunction with the visual image itself. Visualization exercises were initially designed to accommodate groups the size of entire communities, but they can work equally well with smaller groups corresponding to the size of FGDs or group KIIs.

Selecting a Sample of Study Participants

Fundamental differences between qualitative and quantitative approaches to research emerge most clearly in the practice of sampling and recruitment of study participants. Qualitative samples are typically small and purposive. In-depth interview informants are usually selected on the basis of unique characteristics or personal experiences that make them exemplary for the study, if not typical in other respects. Key informants are selected for their unique knowledge or influence in the study domain. Focus group mobilization often seeks participants who are typical with respect to others in the community having similar exposure or shared characteristics. Often, however, participants in qualitative studies are selected because they are exceptional rather than simply representative. Their value lies not in their generalizability but in their ability to generate insight into the key questions driving the study.

Determining Sample Size

Sample size determination for qualitative studies also follows a different logic than that used for probability sample surveys. For example, whereas some qualitative methods specify ideal ranges of participants that constitute a valid observation (e.g., focus groups), there are no rules on how many observations it takes to attain valid results. In theory, sample size in qualitative designs should be determined by the saturation principle , where interviews are conducted until additional interviews yield no additional insights into the topic of research ( 8 ). Practically speaking, designing a study with a range in number of interviews is advisable for providing a level of flexibility if additional interviews are needed to reach clear conclusions.

Recruiting Study Participants

Recruitment strategies for qualitative studies typically involve some degree of participant self-selection (e.g., advertising in public spaces for interested participants) and purposive selection (e.g., identification of key informants). Purposive selection in community settings often requires authorization from local authorities and assistance from local mobilizers before the informed consent process can begin. Clearly specifying eligibility criteria is crucial for minimizing the tendency of study mobilizers to apply their own filters regarding who reflects the community in the best light. In addition to formal eligibility criteria, character traits (e.g., articulate and interested in participating) and convenience (e.g., not too far away) are legitimate considerations for whom to include in the sample. Accommodations to personality and convenience help to ensure the small number of interviews in a typical qualitative design yields maximum value for minimum investment. This is one reason why random sampling of qualitative informants is not only unnecessary but also potentially counterproductive.

Analysis of qualitative data can be divided into four stages: data management, data condensation, data display, and drawing and verifying conclusions ( 9 ).

Managing Qualitative Data

From the outset, developing a clear organization system for qualitative data is important. Ideally, naming conventions for original data files and subsequent analysis should be recorded in a data dictionary file that includes dates, locations, defining individual or group characteristics, interviewer characteristics, and other defining features. Digital recordings of interviews or visualization products should be reviewed to ensure fidelity of analyzed data to original observations. If ethics agreements require that no names or identifying characteristics be recorded, all individual names must be removed from final transcriptions before analysis begins. If data are analyzed by using textual data analysis software, maintaining careful version control over the data files is crucial, especially when multiple coders are involved.

Condensing Qualitative Data

Condensing refers to the process of selecting, focusing, simplifying, and abstracting the data available at the time of the original observation, then transforming the condensed data into a data set that can be analyzed. In qualitative research, most of the time investment required to complete a study comes after the fieldwork is complete. A single hour of taped individual interview can take a full day to transcribe and additional time to translate if necessary. Group interviews can take even longer because of the difficulty of transcribing active group input. Each stage of data condensation involves multiple decisions that require clear rules and close supervision. A typical challenge is finding the right balance between fidelity to the rhythm and texture of original language and clarity of the translated version in the language of analysis. For example, discussions among groups with little or no education should not emerge after the transcription (and translation) process sounding like university graduates. Judgment must be exercised about which terms should be translated and which terms should be kept in vernacular because there is no appropriate term in English to capture the richness of its meaning.

Displaying Qualitative Data

After the initial condensation, qualitative analysis depends on how the data are displayed. Decisions regarding how data are summarized and laid out to facilitate comparison influence the depth and detail of the investigation’s conclusions. Displays might range from full verbatim transcripts of interviews to bulleted summaries or distilled summaries of interview notes. In a field setting, a useful and commonly used display format is an overview chart in which key themes or research questions are listed in rows in a word processer table or in a spreadsheet and individual informant or group entry characteristics are listed across columns. Overview charts are useful because they allow easy, systematic comparison of results.

Drawing and Verifying Conclusions

Analyzing qualitative data is an iterative and ideally interactive process that leads to rigorous and systematic interpretation of textual or visual data. At least four common steps are involved:

• Reading and rereading. The core of qualitative analysis is careful, systematic, and repeated reading of text to identify consistent themes and interconnections emerging from the data. The act of repeated reading inevitably yields new themes, connections, and deeper meanings from the first reading. Reading the full text of interviews multiple times before subdividing according to coded themes is key to appreciating the full context and flow of each interview before subdividing and extracting coded sections of text for separate analysis.
• Coding. A common technique in qualitative analysis involves developing codes for labeling sections of text for selective retrieval in later stages of analysis and verification. Different approaches can be used for textual coding. One approach, structural coding , follows the structure of the interview guide. Another approach, thematic coding , labels common themes that appear across interviews, whether by design of the topic guide or emerging themes assigned based on further analysis. To avoid the problem of shift and drift in codes across time or multiple coders, qualitative investigators should develop a standard codebook with written definitions and rules about when codes should start and stop. Coding is also an iterative process in which new codes that emerge from repeated reading are layered on top of existing codes. Development and refinement of the codebook is inseparably part of the analysis.
• Analyzing and writing memos. As codes are being developed and refined, answers to the original research question should begin to emerge. Coding can facilitate that process through selective text retrieval during which similarities within and between coding categories can be extracted and compared systematically. Because no p values can be derived in qualitative analyses to mark the transition from tentative to firm conclusions, standard practice is to write memos to record evolving insights and emerging patterns in the data and how they relate to the original research questions. Writing memos is intended to catalyze further thinking about the data, thus initiating new connections that can lead to further coding and deeper understanding.
• Verifying conclusions. Analysis rigor depends as much on the thoroughness of the cross-examination and attempt to find alternative conclusions as on the quality of original conclusions. Cross-examining conclusions can occur in different ways. One way is encouraging regular interaction between analysts to challenge conclusions and pose alternative explanations for the same data. Another way is quizzing the data (i.e., retrieving coded segments by using Boolean logic to systematically compare code contents where they overlap with other codes or informant characteristics). If alternative explanations for initial conclusions are more difficult to justify, confidence in those conclusions is strengthened.

Above all, qualitative data analysis requires sufficient time and immersion in the data. Computer textual software programs can facilitate selective text retrieval and quizzing the data, but discerning patterns and arriving at conclusions can be done only by the analysts. This requirement involves intensive reading and rereading, developing codebooks and coding, discussing and debating, revising codebooks, and recoding as needed until clear patterns emerge from the data. Although quality and depth of analysis is usually proportional to the time invested, a number of techniques, including some mentioned earlier, can be used to expedite analysis under field conditions.

• Detailed notes instead of full transcriptions. Assigning one or two note-takers to an interview can be considered where the time needed for full transcription and translation is not feasible. Even if plans are in place for full transcriptions after fieldwork, asking note-takers to submit organized summary notes is a useful technique for getting real-time feedback on interview content and making adjustments to topic guides or interviewer training as needed.
• Summary overview charts for thematic coding. (See discussion under “Displaying Data.”) If there is limited time for full transcription and/or systematic coding of text interviews using textual analysis software in the field, an overview chart is a useful technique for rapid manual coding.
• Thematic extract files. This is a slightly expanded version of manual thematic coding that is useful when full transcriptions of interviews are available. With use of a word processing program, files can be sectioned according to themes, or separate files can be created for each theme. Relevant extracts from transcripts or analyst notes can be copied and pasted into files or sections of files corresponding to each theme. This is particularly useful for storing appropriate quotes that can be used to illustrate thematic conclusions in final reports or manuscripts.
• Teamwork. Qualitative analysis can be performed by a single analyst, but it is usually beneficial to involve more than one. Qualitative conclusions involve subjective judgment calls. Having more than one coder or analyst working on a project enables more interactive discussion and debate before reaching consensus on conclusions.
• Systematic coding.
• Selective retrieval of coded segments.
• Verifying conclusions (“quizzing the data”).
• Working on larger data sets with multiple separate files.
• Working in teams with multiple coders to allow intercoder reliability to be measured and monitored.

The most widely used software packages (e.g., NVivo [QSR International Pty. Ltd., Melbourne, VIC, Australia] and ATLAS.ti [Scientific Software Development GmbH, Berlin, Germany]) evolved to include sophisticated analytic features covering a wide array of applications but are relatively expensive in terms of license cost and initial investment in time and training. A promising development is the advent of free or low-cost Web-based services (e.g., Dedoose [Sociocultural Research Consultants LLC, Manhattan Beach, CA]) that have many of the same analytic features on a more affordable subscription basis and that enable local research counterparts to remain engaged through the analysis phase (see Teamwork criteria). The start-up costs of computer-assisted analysis need to be weighed against their analytic benefits, which tend to decline with the volume and complexity of data to be analyzed. For rapid situational analyses or small scale qualitative studies (e.g. fewer than 30 observations as an informal rule of thumb), manual coding and analysis using word processing or spreadsheet programs is faster and sufficient to enable rigorous analysis and verification of conclusions.

Qualitative methods belong to a branch of social science inquiry that emphasizes the importance of context, subjective meanings, and motivations in understanding human behavior patterns. Qualitative approaches definitionally rely on open-ended, semistructured, non-numeric strategies for asking questions and recording responses. Conclusions are drawn from systematic visual or textual analysis involving repeated reading, coding, and organizing information into structured and emerging themes. Because textual analysis is relatively time-and skill-intensive, qualitative samples tend to be small and purposively selected to yield the maximum amount of information from the minimum amount of data collection. Although qualitative approaches cannot provide representative or generalizable findings in a statistical sense, they can offer an unparalleled level of detail, nuance, and naturalistic insight into the chosen subject of study. Qualitative methods enable investigators to “hear the voice” of the researched in a way that questionnaire methods, even with the occasional open-ended response option, cannot.

Whether or when to use qualitative methods in field epidemiology studies ultimately depends on the nature of the public health question to be answered. Qualitative approaches make sense when a study question about behavior patterns or program performance leads with why, why not , or how . Similarly, they are appropriate when the answer to the study question depends on understanding the problem from the perspective of social actors in real-life settings or when the object of study cannot be adequately captured, quantified, or categorized through a battery of closed-ended survey questions (e.g., stigma or the foundation of health beliefs). Another justification for qualitative methods occurs when the topic is especially sensitive or subject to strong social desirability biases that require developing trust with the informant and persistent probing to reach the truth. Finally, qualitative methods make sense when the study question is exploratory in nature, where this approach enables the investigator the freedom and flexibility to adjust topic guides and probe beyond the original topic guides.

Given that the conditions just described probably apply more often than not in everyday field epidemiology, it might be surprising that such approaches are not incorporated more routinely into standard epidemiologic training. Part of the answer might have to do with the subjective element in qualitative sampling and analysis that seems at odds with core scientific values of objectivity. Part of it might have to do with the skill requirements for good qualitative interviewing, which are generally more difficult to find than those required for routine survey interviewing.

For the field epidemiologist unfamiliar with qualitative study design, it is important to emphasize that obtaining important insights from applying basic approaches is possible, even without a seasoned team of qualitative researchers on hand to do the work. The flexibility of qualitative methods also tends to make them forgiving with practice and persistence. Beyond the required study approvals and ethical clearances, the basic essential requirements for collecting qualitative data in field settings start with an interviewer having a strong command of the research question, basic interactive and language skills, and a healthy sense of curiosity, armed with a simple open-ended topic guide and a tape recorder or note-taker to capture the key points of the discussion. Readily available manuals on qualitative study design, methods, and analysis can provide additional guidance to improve the quality of data collection and analysis.

• Patton MQ. Qualitative research and evaluation methods: integrating theory and practice . 4th ed. Thousand Oaks, CA: Sage; 2015.
• Hennink M, Hutter I, Bailey A. Qualitative research methods . Thousand Oaks, CA: Sage; 2010.
• Lincoln YS, Guba EG. The constructivist credo . Walnut Creek, CA: Left Coast Press; 2013.
• Mack N, Woodsong C, MacQueen KM, Guest G, Namey E. Qualitative research methods: a data collectors field guide. https://www.fhi360.org/sites/default/files/media/documents/Qualitative%20Research%20Methods%20-%20A%20Data%20Collector%27s%20Field%20Guide.pdf
• Kvale S, Brinkmann S. Interviews: learning the craft of qualitative research . Thousand Oaks, CA: Sage; 2009:230–43.
• Krueger RA, Casey MA. Focus groups: a practical guide for applied research . Thousand Oaks, CA: Sage; 2014.
• Margolis E, Pauwels L. The Sage handbook of visual research methods . Thousand Oaks, CA: Sage; 2011.
• Mason M. Sample size and saturation in PhD studies using qualitative interviews. Forum : Qualitative Social Research/Sozialforschung. 2010;11(3).
• Miles MB, Huberman AM, Saldana J. Qualitative data analysis: a methods sourcebook . 3rd ed. Thousand Oaks, CA: Sage; 2014.
• Silver C, Lewins A. Using software in qualitative research: a step-by-step guide . Thousand Oaks, CA; Sage: 2014.

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InterTASC ISSG Search Filter Resource A list of references describing filters to identify qualitative research MEDLINE (Ovid and PubMed), CINAHL, EMBASE, and PsycINFO. From Centre for Reviews and Dissemination, University of York and National Institute for Health Research, UK.

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• Use the following keywords to identify qualitative research. These keywprds will search the titles, abstracts and keywords of records held in the databases. Use quotations to search as a phrase:

Use controlled vocabulary

Databases use controlled vocabulary to categorize each record stored. The terms they use are known as  thesaurus terms or subject headings .  The thesaurus terms vary for each database according to their indexing system.

For example, qualitative research is indexed in PubMed as "Qualitative Research" or "Nursing Methodology Research", while in CINAHL their subject heading "Qualitative Studies" is complemented by more detailed terms, including "Phenomenological Research" and "Grounded Theory".

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Qualitative research filters are pre-formulated search strategies that have been constructed by librarians to help you retrieve articles in databases that deal with qualitative research. You can use the filter and then combine the results with your subject.

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PubMed Topic Specific Queries

• Go to  http://www.ncbi.nlm.nih.gov/pubmed/
• Under PubMed Tools , click Topic Specific Queries
• In the left column, click   Health Services Research (HSR) Queries
• Enter your search topic
• Under Category select Qualitative Research  
• Go to PsychINFO database in Database Finder .
• Enter your topic in the search box.
• In right column, under Methodoly, MATHEMATICAL MODEL , select Qualitative study .
• Under Refine Search section on the left, limit further your search under Methodology drop down menu.

Modify your search strategy accordingly by using thesaurus terms, such as qualitative research, grounded theory, interviews, observation methods, etc.

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Qualitative Research and its Uses in Health Care

Although relatively uncommon in health care research, qualitative research is now receiving recognition and is increasingly used in health care research with social and cultural dimensions. Unlike quantitative research, which is deductive and tends to analyze phenomena in terms of trends and frequencies, qualitative research seeks to determine the meaning of a phenomenon through description. It aims to develop concepts that aid in the understanding of natural phenomena with emphasis on the meaning, experiences and views of the participants. Differences among qualitative researchers exist on matters of ontology, epistemology, data collection methods and methods of evaluation. The aim of this article is not to act as a practical guide on how to conduct qualitative research, but is an attempt to give an introduction to qualitative research methods and their use in health-related research.

Q ualitative research is defined as an umbrella term covering an array of interpretative techniques which seek to describe, decode, translate and otherwise come to terms with the meaning, not the frequency, of certain more or less naturally occurring phenomena in the social world. 1 , 2

As a method of inquiry, it was first used by sociologists and anthropologists in the early twentieth century, although it existed much earlier than that in its non-structural form. Researchers studied cultures and groups in their own and foreign settings and told stories of their experience long before then. In the 1920s and 1930s, social anthropologists and sociologists implemented a more focused approach compared to the old unsystematic and journalistic style used in those days. Since the 1960s, qualitative research has experienced a steady growth starting with the development of grounded theory and new publications in ethnography. 3 , 4 The number of books, articles and papers related to qualitative research has increased tremendously during the past 20 years and more researchers, including health-related professionals, have moved to a more qualitative paradigm adapting and modifying these approaches to the study needs of their own areas. 4

Since qualitative research does not aim to enumerate, it is sometimes viewed as the exact opposite to quantitative methods and the two methods are frequently presented as antagonists. Quantitative research is based on structure and uses experiments and surveys as methods. In addition, it is deductive in nature and uses statistical sampling methods. In contrast, qualitative research is described as an action research using observation and interview methods. It is inductive in nature and depends on the purposeful selection of participants. Whereas quantitative researchers use reliability as a way of verification, qualitative researchers use validity. Recently, there has been a growing recognition that the quantitative-qualitative debate and distinction is unnecessary and that it would be more fruitful for the relation between the two methods to be complementary and overlapping rather than exclusive. 6 In fact, neither qualitative nor quantitative research is superior to the other; there are weaknesses and strengths in each method. Qualitative and quantitative research methods can indeed be seen as complementary and both are necessary to provide an understanding of a phenomenon.

Several researchers have argued that the research questions and the phenomenon under investigation should determine the methodology to used. 7 , 8 , 9 The crucial question, therefore, is not “what is the best research method?” but “what is the best research method for answering this question most effectively and efficiently?” 10 So, while qualitative and quantitative research may well investigate similar topics, each will address a different type of question. Holman sums up this position: “true understanding in medicine cannot be achieved without adding qualitative methods to the research arsenal”. 11

Traditional quantitative methods, such as randomised controlled trials, are the appropriate means of testing, for example, the effect of an intervention or a treatment, while a qualitative exploration of beliefs and understandings is needed to find out why the results of research are often not implemented in clinical practice. The aim of qualitative research is to develop concepts that can help us understand social phenomena in natural settings, giving emphasis on the meanings, experiences and views of the participants. 10

Qualitative research methods are the most suitable for this approach because of their emphasis on people’s lived experience. They are considered to be well suited for locating the meanings that people place on the events, processes, and structures of their lives and their perceptions, presuppositions and assumptions. 5 In his advice to graduate students, Patton lists a number of conditions that are suitable for a qualitative study. These include: questions about people’s experiences; inquiry into the meanings people make of their experiences; studying a person in the context of her or his social/interpersonal environment and research where it is difficult to develop a standardised instrument due to the lack of knowledge on the phenomenon. 12

ARGUMENTS FOR AND AGAINST QUALITATIVE METHODS

There are major differences of opinions among qualitative researchers on matters of ontology and epistemology as well as the methods to be used and criteria of evaluation. There are also disagreements about the nature, purpose, status and practice of its methods. A large number of authors take a predominantly method-based approach; authors such as Miles and Huberman 5 and Patton 12 put emphasis on data collection techniques. Another approach is to classify qualitative research according to research traditions, i.e. whether phenomenological, grounded theory or ethnography, amongst others. Authors such as Creswel 9 and Denzin and Lincolin 3 prefer this approach, which has the advantage of being based on systematisation of knowledge providing a sense of order and orientation. On the other hand, it has the disadvantage of oversimplification, ignoring the issues of the research question and conceptual frameworks used and the way these issues can shape the research process and the findings. 13 In addition, some researchers have decided to classify qualitative research according to the research question or the method of analysis.

Although the majority of qualitative researchers stress that qualitative research is inductive in nature, in contrast to quantitative research which is deductive, there are qualitative researchers who argue that both can be used for different purposes and at different times, and that qualitative research can be done in a deductive way where prior assumptions are tested on new cases. 14 Retroduction, which is defined as the movement backward and forward between theory and data or the combination of deduction and induction, is said to be a characteristic of qualitative research. 11 The degree of deduction or induction and which one follows the other depends on the research question. 12 .

Guba and Lincoln 15 used the term “emergent design” to describe a qualitative study design that emerges as the study progresses in response to the researcher’s early observations. There are also qualitative studies in health care that base their research questions on the results of prior literature of quantitative studies on the subject. 16 , 17 While the research questions in these studies were relatively precise, the method used was flexible.

Miles and Huberman 5 state that no study conforms exactly to a standard methodology and that the researcher bends the methodology to the peculiarities of the study. According to Creswell, 9 traditions of inquiry used “need not be pure, and one might mix procedures from several”. Mixing approaches and procedures is encouraged by some authors and regarded as a creative approach to qualitative research. 12

Studies using qualitative research in health care have been criticised for the misguided separation of method from theory and of technique from the conceptual underpinnings. 18 However, qualitative health researchers respond by stating that the choice of method and how it is used can perfectly well be matched to what is being studied rather than to the methodological leanings of the researcher. 10 It has been suggested that incorporating qualitative research method experts into health research teams enriches research and ensures that the right methodology is used for answering the right questions. Finally, using qualitative methods in health-related research has resulted in more insight into health professionals’ perceptions of lay participation in care and identification of barriers to changing healthcare practice.

QUALITATIVE RESEARCH APPROACHES

Grounded theory, phenomenology and ethnography are three approaches used in qualitative research. Grounded theory approach is a commonly used qualitative method in the social sciences to inductively generate or discover a theory out of the data. 9 Phenomenology and ethnography are more commonly used qualitative approaches in health care and will be highlighted below.

PHENOMENOLOGY

One of the major strengths of qualitative research is its emphasis upon understanding the phenomenon of interest holistically and in its context. The term phenomenology is popular and widely embraced, but its meaning has become confusing and faint. Different researchers refer to phenomenology differently. It can refer to an inquiry paradigm, an interpretive theory, a philosophy, an analytical perspective, a major qualitative research tradition or a research method framework. 12

In spite of the differences, all of these approaches share the focus of phenomenology, which is exploring how human beings make sense of experience and the meaning they give to these experiences. Phenomenology is being used in the social and human sciences including sociology, education, psychology, nursing and health sciences. 9

Phenomenologists are interested in how people put together the phenomena they experience in such a way as to make sense of the world and develop a worldview. They assume commonality in human experience and focus on meaning-making as the essence of human experience. The essence is the core meaning mutually understood through a phenomenon commonly experienced. 12 The phenomenon under study may be emotions, relationships, a programme, an organisation or a culture. 12 Bracketing is one of the central ideas in phenomenology. It means that the researcher has to set aside all of his prejudgments and his previous experience about the phenomena and approach the field with an open mind, imagination and intuition. Although important, bracketing is often said to be a difficult task. 9

Patton 12 describes the difference between conducting a phenomenological study and using a phenomenological perspective to a study. He argues that, “one can employ a general phenomenological perspective to elucidate the importance of using methods that capture people’s experience of the world without conducting a phenomenological study that focuses on the essence of shared experience”.

ETHNOGRAPHY

In ethnography, the researcher studies the structure and function of a group of people. An example of a structure or configuration is the kinship, while the function refers to patterns of relationships affecting and regulating behaviour. 9 The aim of ethnographic studies is to give a holistic picture of the social group studied, attempting to describe aspects of the cultural and social system of that particular group. These aspects could be the group history, religion, economy, politics or environment.

Data collection methods vary in ethnographic studies with observation and interviews being the most popular methods. Although some authors expressed concern that anthropological methods may be misused or applied superficially by the medical profession, 19 others, however, expressed the need for acknowledging and incorporating ethnographic methods in health care research. 20 Savage 19 explains that today the term ethnography can be applied to any small-scale social research carried out in everyday settings and uses several methods evolving in design and focusing on an individual’s meanings and explanations. In health care, ethnography has been used in topics related to health beliefs and practices, allowing these issues to be viewed in the context in which they occur and therefore helping broaden the understanding of behaviours related to health and illness. 20

In addition, there has been an increase in the amount of cross-cultural research and a change in the form of this research. Recently, more short-term ethnographic and cross-cultural studies have been undertaken, for example, studies sponsored by international development agencies or student exchange projects. 12

QUALITATIVE RESEARCH INSTRUMENTS

Qualitative research instruments used for data collection include interviews, observations, and analysis of documents. Interviews are the most common techniques used to gather research information. There are three types of interviews: structured, semi-structured and unstructured, described in some books as structured, informed and guided, respectively. 13

The semi-structured interview is more commonly used in health care-related qualitative research. Such an interview is characteristically based on a flexible topic guide that provides a loose structure of open-ended questions to explore experiences and attitudes. It has the advantage of great flexibility, enabling the researcher to enter new areas and produce richer data. In addition, it helps the researcher to develop a rapport with the informants. Semi-structured interviews elicit people’s own views and descriptions and have the benefit of uncovering issues or concerns that have not been anticipated by the researcher. 6 They are commonly used when the aim is to gain information on the perspectives, understandings and meanings constructed by people regarding the events and experiences of their lives. However, this type of interviewing is claimed to reduce the researcher’s control over the interview situation and take a longer time to conduct and analyse, in addition to the difficulties of the analysis process. 21

In health care, interviews are the appropriate tool to be used if the research is concerned with interpersonal aspects of care or if the available evidence is limited. 6

Another qualitative research instrument that can be used in health care research is the focus group. Focus group interviews have the advantage of being more time efficient as more people can be interviewed for the same amount of time. They also provide a richer source of data. On the other hand, focus group interviews tend to document the ‘public’ rather than the ‘private’ views of the individuals. In addition some people do not interview well in-group situations. 13

THE USE OF THE INTERVIEW GUIDE

Some qualitative researchers are reluctant to plan a design of their study in advance of the data collection. They argue that the phenomenon studied must first be discovered and they describe their design as emergent. However, increasingly more qualitative researchers appear ready to define a research question and develop an interview guide prior to starting the data collection. 11 Patton defines an interview guide as a series of topics or broad interview questions which the researcher is free to explore and probe with the interviewee. 12 The advantage of an interview guide is that it helps the interviewer pursue the same basic lines of inquiry with each person interviewed and manage the interviews in a more systematic and comprehensive way. The findings of earlier work are increasingly being used as a facilitator for further research. However, concepts drawn from earlier work are supposed to be held lightly and to be subject to reformulation or rejection by the researcher especially as the study goes on and the research progresses. 11 The extent to which such a flexibility of design is important will vary depending on the topic and the aim of the study.

Sampling strategies in qualitative research are largely determined by the purpose of the study. Statistical representativeness is not considered as a prime requirement in qualitative research and is not normally sought. Furthermore, qualitative data collection is more time consuming and expensive, which makes the use of a probability sample impractical. 6 The aim of sampling in qualitative research is to identify specific groups of people who hold characteristics or live in circumstances relevant to the phenomena being studied. In this way, identified informants are expected to enable enriched exploration of attitudes and aspects of behaviour relevant to the research. 10 Two types of samples used in qualitative research, maximum variation and homogenous samples, are explained below.

According to Patton, 12 maximum variation sampling is where the researcher attempts to study a phenomenon by seeking out settings or persons that represent the greatest differences in that phenomenon. A maximum variation sample documents diverse variations and identifies important common patterns by representing diverse cases to develop fully multiple perspectives about the cases. 9 This means that the participants are sampled based on particular predetermined criteria in order to cover a range of constituencies, such as different age, cultural background or class. 6

Similarly, the researcher can select the setting of the data collection on the basis that it is sufficiently similar to other settings in which generalisation is sought. This way the researcher is demonstrating the possibility that the setting studied is representative of the population studied. 2

In homogeneous sampling, the researcher chooses a small homogenous sample with the purpose of describing some particular subgroups in depth. 12

The sample size in qualitative research is not determined by fixed rules, but by factors such as the depth and duration of the interview and what is feasible for a single interviewer. 22 Although it is theoretically possible to carry out qualitative research on large samples, qualitative researchers find themselves obliged by time and resource limits to trade breadth for depth. 11 The sample size for interview studies is usually much smaller than those of a quantitative research, usually not exceeding 50 participants, although this can vary with the research question asked. 6 Patton 12 states, “there are no rules for sample size in qualitative inquiry”. In other words, sample size depends on the aim of the study and what is possible, given the time and resources available.

ANALYSING QUALITATIVE RESEARCH

Although there are plenty of guidelines for analysing qualitative research, applying these guidelines requires judgment and creativity because each qualitative study is unique. 12 A researcher might also be confused by the different terms used by qualitative researchers when describing analysis. Analysis might be described as interpretation, making sense of data, or transforming data. Analysis is sometimes presented to indicate different procedures based on language, theory or what is described as interpretive/descriptive analysis. 11 However, overlap can take place between these different methods and a researcher might decide to use a method of analysis that is based on language, such as symbolic interactionist, while using grounded theory to develop a theory at the same time. Most of the analytical approaches to qualitative research in health care are ‘generic’ and are not labelled within one of the specific traditions of qualitative research. A common approach in most of these studies is general and inductive in nature, but does not comply with the very systematic and rigorous inductive approach of grounded theory. In addition, it has been described that many researchers use a simple two-level analysis scheme followed by a more specific level. This means that the researcher can initiate the analysis based on the conceptual framework used in order to produce more inductive data, and the coding moves from the descriptive to the more interpretative and inferential codes. 5

COMPUTER USE IN QUALITATIVE DATA ANALYSIS

Qualitative research studies typically produce very large amount of data that needs to be managed efficiently. Computer packages can improve the efficiency of data management. 11 Computer programs provide a way of storing and retrieving material. They are therefore useful in locating cases, statements, phrases or even words, thereby replacing the tedious and time-consuming process of “cutting and pasting” and “colour coding”. The use of computer packages, however, is claimed to distance the analyst from the data, 11 and may take the place of a close and careful analysis. Using a computer programme can lead to quantitative analysis instead of qualitative, for example, counting occurrences, giving more weight to more frequent events, and ignoring isolated incidences. 23 In addition, computer programmes are said to fix and label categories during the analysis process and the researcher may be reluctant to change these categories. 9 Furthermore, the researcher is required to learn the computer programme, which may add to the time and effort he or she will need to spend on the research project. The researcher also has to be aware of the limitations of computer programmes. While computer packages can help with the intensive process of analysis and the management of large data sets, they are not a substitute for “immersion” in the data, and thorough knowledge that can enable the researcher to make comparisons, identify patterns and develop interpretations. 6 There are different packages available: Ethnograph, Atlas and NUD.IST are the mostly used. QSR NVivo is a new product developed by the makers of NUD.IST and is user-friendlier, more suitable for individual research projects and more visually attractive than previous packages.

THE ROLE OF THE RESEARCHER IN QUALITATIVE RESEARCH

Patton 12 states that, “the human element in qualitative research is both its strength and weakness”. It is considered a point of strength because it allows human insight and experience to develop new understandings of the world, and a point of weakness because it depends heavily on the researcher’s skills, creativity, training and intellect. Qualitative methods depend on both critical and creative thinking and the balance between the two in conducting the study and interpreting its results. The role of the researcher is approached differently according to the type of research tradition used. A phenomenologist researcher is required to bracket his/her own assumptions when collecting data. On the other hand, in an ethnographic study, the effect of the researcher on the interview and the interaction is seen as inevitable and important in shaping the results of the study.

Although practising clinicians routinely interview patients during their clinical work, interviewing is a well-established technique in sociology and related disciplines. One of the differences between clinical and research-aimed interviews lies in their different purposes. The usual aim of the clinical interview is to fit the patient’s problem into the appropriate medical category for diagnosis and management. On the other hand, the aim of a qualitative research interview is to discover the interviewee’s own meaning and avoid prior assumptions and preset categories. 22 Having said that, there are general skills in clinical interviewing that can be useful, such as listening and observation. A good level of self-awareness is necessary in the researcher in order to reduce possible biases.

Researchers in qualitative research need to consider how they are perceived by interviewees and the effect of features related to the researcher, such as class, race, and sex on the interview. This question is more important if the interviewee knows that the interviewer is a doctor. It has been described that a patient, or someone who is likely to be become one, may give what he or she thinks is a desirable response, thinking that the doctor will be pleased.

RIGOUR IN QUALITATIVE RESEARCH

Health field research is generally quantitative and based on biomedical traditions and experimental methods. In this field, qualitative research is criticized for being subject to researcher bias and for lacking reproducibility and generalisability. 10 Researchers presenting their qualitative work in health-related research are partly responsible for this view. Many qualitative researchers neglect the importance of giving an adequate description of their theoretical concepts and methods used in their research. A systematic research method is also essential when conducting qualitative research. Rigour in qualitative research includes procedures taken at different stages of the research process including during data collection and analysis. Several procedures have been described to increase rigour in qualitative research. For example, triangulation is commonly used as a way of validating of data.

TRIANGULATION

In triangulation, the researcher uses multiple methods, sources, researchers or theories to provide evidence that strengthens his or her study. Triangulation provides different ways of looking at the same phenomenon and adds credibility and confidence in the conclusions drawn from the study. There are two main types of triangulation, triangulation of sources and analyst triangulation. Patton 12 defines triangulation of sources as “checking out the consistency of different data sources within the same method”. When using this type of triangulation, the researcher compares the perspectives of people from different points of view. For example, studies in programme evaluation might compare the views of staff, clients or funding bodies. 12 Studies in health care have used this method of verification to study the accounts of doctors, patients, and managers in order to identify similarities and differences in views. An example is the study of patients’ versus doctors’ agendas in general practice. 23 Both similarities and differences from different sources, when given reasonable explanation, could contribute significantly to the credibility of the findings. Triangulation with multiple analysts can also be used as a method of verification. It is defined as “having two or more persons independently analyse the same qualitative data and compare their findings”. 12

QUALITATIVE RESEARCH IN HEALTH CARE MANAGEMENT

Recently, there has been a greater acceptance of the qualitative approach, even as a stand-alone method, in health care research. Institutions that control funding for medical research have developed ethical guidelines for assessing qualitative studies which indicates formal acceptance of this form of research within an area previously dominated by quantitative methods. 13 More qualitative research articles are published in health-related journals, in addition to a new qualitative research journal (Qualitative Health Research).

Quality of health care is one of the areas where qualitative methods can be used. The concept of quality in health care is multidimensional and multifaceted and some of the questions asked related to the quality of care or services may not be acquiescent to quantitative methods. 6 Qualitative research offers a variety of methods to be used for identifying what is really important to both patients and carers. It can also be used to identify and detect obstacles to change and the reasons why improvement does not occur. 6 It is therefore an essential component of health services research because it enables us to reach areas not amenable to quantitative research, for example, lay and professional health beliefs. In addition, qualitative description can be a prerequisite of quantitative research, particularly in areas that have received little previous investigation.

Qualitative research is widely used to study issues related to doctor-patient interaction especially in general practice. Studies concerning patients’ versus doctors’ agendas in general practice and general practitioners perceptions of effective health care are examples. 23 , 24 Recently there have been more studies concentrating on patients’ own perceptions and views regarding their health and health care services, for example a study on women’s views on the impact of operative delivery in the second stage of labour. 25 Another example is the study on middle-aged person’s experience of living with severe heart failure. 26

Another area where qualitative research is being used in health care is to identify obstacles and barriers to practice change by exploring the reasons behind certain behaviours. A good example of this is the study of patients’ decisions about whether or not to take anti-hypertensive drugs. 27 There are similar studies on issues such as the use of antibiotics in general practice and patient compliance.

In addition to issues related to the patients’ perception, some qualitative studies concentrated on factors fostering the doctor’s motivation and the effect of doctors’ social life and culture, in addition to issues related to the doctor’s own health. Examples are the study by Dumelow et al. 28 on the relation between a career and family life for English hospital consultants. Another example is a study aimed at exploring general practitioners’ perceptions of the effects of their profession and training on their attitudes to illness in themselves and colleagues. 29

Qualitative work can help in identifying cultural and social factors that affect health care positively or negatively. Such information can be helpful in improving service delivery. 6 Studies on patients from ethnic minorities have identified administrative and language barriers that affected health care and shed light on some of the beliefs and behaviours of these patients that might have affected help seeking and compliance. Good examples are the studies by Bush et al. 30 exploring the influences on smoking in Bangladeshi and Pakistani adults in the UK, and the multi-centre cross-cultural postnatal depression study. 31

There has been an increasing interest and use of qualitative research methods in primary health care and general practice articles. Britten 32 states that “the nature of general practice is such that a variety of research methods are needed to explore all its intricacies” He adds that qualitative methods can enrich research in general practice by opening up areas not amenable to quantitative methods, topics such as patient satisfaction, doctor-patient interaction, in addition to identifying and explaining attitudes, beliefs and behaviour. In addition, qualitative research has been used in the assessment of new technology methods used in health care. For example, the studies on the implementation of the National Health System information technology programme in the UK. 11 , 33

Qualitative research methods are receiving an increasing recognition in health care related research. The use of qualitative research in health care enables researchers to answer questions that may not be easily answered by quantitative methods. Moreover, it seeks to understand the phenomenon under study in the context of the culture or the setting in which it has been studied, therefore, aiding in the development of new research instruments, such as questionnaires that are more culturally acceptable. However, because health care related research has, for decades, been based on quantitative methods, the introduction of a new method requires researchers in health care who attempt to use it, to have a thorough understanding of its theoretical basis, methodology and evaluation techniques.

Acknowledgments

I would like to thank Sultan Qaboos University, Oman, for granting me a scholarship to do my PhD at the University of Nottingham, UK. I am also grateful to my PhD supervisor, Dr Margaret Oates, for her guidance and support.

Digital Health Research Methods and Global Public Health

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• Rayner K. J. Tan 2 , 3 ,
• Pearlyn H. M. Neo 3 ,
• Jane M. Lim 4 &
• Suan Ee Ong 3 , 5  

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The advent of technology has brought about new opportunities and interfaces to generate insights into individuals’ and societies’ social worlds and lived experiences. This chapter highlights broad trends in technological innovations and the concomitant rise of digital research methods. First, it explores the mediating role of technology in both accessing the social lives of individuals and understanding realities where novel interactions are easily generated. Second, it highlights how the advent of different technologies, including the internet and social media, personal handheld devices and wearables, as well as big data sources have led to a broadening and deepening of digital research methods. Third, it discusses the benefits of these approaches in the context of global public health. Finally, the chapter discusses several issues relating to the digital divide that must be addressed to realize the potential of digital research methods in furthering efforts to improve global public health.

• Virtual research methods
• Digital research methods
• Digitization
• Digital health
• Methodological innovation

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Tan, R.K.J., Neo, P.H.M., Lim, J.M., Ong, S.E. (2023). Digital Health Research Methods and Global Public Health. In: Liamputtong, P. (eds) Handbook of Social Sciences and Global Public Health. Springer, Cham. https://doi.org/10.1007/978-3-030-96778-9_54-1

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DOI : https://doi.org/10.1007/978-3-030-96778-9_54-1

Received : 14 September 2022

Accepted : 15 September 2022

Published : 07 February 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-96778-9

Online ISBN : 978-3-030-96778-9

eBook Packages : Springer Reference Social Sciences Reference Module Humanities and Social Sciences Reference Module Business, Economics and Social Sciences

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Master of Public Health

Public health research methods.

Advancing the evidence base on ways to promote health equity requires a solid foundation of research methods skills. Finding answers to complex questions on how to improve public health requires carefully designed research and evaluation studies with results that can be used to shape policy, programs, and interventions. Employers in government, academia, nongovernmental organizations, and private industry across the globe seek candidates with strong skills in data collection, analysis, and interpretation; research and evaluation design; and working in diverse, complex contexts. 

The Certificate in Public Health Research Methods (PHRM) provides students from various disciplines with the critical skills they need to design, conduct, and analyze data from health studies, particularly those that have direct implications for practice, programs, and policy. This rigorous certificate provides students with a well-rounded foundation of skills gleaned from coursework and co-curricular programming that emphasizes career development and application of methods in practice.  

Admissions Eligibility

Public Health Research Methods is open to Columbia MPH students in the following departments:

• Biostatistics
• Environmental Health Sciences
• Epidemiology
• Health Policy and Management
• Population and Family Health
• Sociomedical Sciences

Given the required classes, the program is best suited to students enrolled in Epidemiology , Population and Family Health or Sociomedical Sciences .

The Competencies for this Certificate are as follows:

• Generate and test public health research and evaluation hypotheses using quantitative and qualitative research methodologies.
• Select study designs and sampling and data collection strategies best suited to a given research or evaluation question, which are maximally rigorous, and feasible given the context and practical constraints of the setting.
• Critically evaluate the internal and external validity of quantitative and qualitative research methods and/or findings
• Execute qualitative and quantitative data analysis plans that will answer the research and evaluation question.
• Communicate accurately and effectively to a range of audiences about public health research

Visit the  Certificates Database  to learn more about core and credit requirements.

Sample Courses

Evaluation of health programs.

Program evaluation is an essential competence in public health. Across all areas of public health, stakeholders pose questions about effectiveness and impact of programs and interventions. This course will examine principles, methods and practices of evaluating health programs. A range of evaluation research designs and methods will be introduced and strategies to address challenges in real world program settings will be emphasized. The course will incorporate examples of evaluations of actual health programs and opportunities to learn through professional program evaluation experiences of the instructor. The combination of lectures, textbook readings, examples, discussions, in-class exercises, and an extensive applied group assignment to design an evaluation for a real program will help students gain evaluation skills and an appreciation for the art and science of program evaluation. The goal is for students to learn competencies required of an entry-level program evaluator, including design and implementation of evaluation studies and interpretation and communication of evaluation findings. 

Quantitative Data Analysis

In this course students will learn to develop and implement a quantitative data analysis plan and to interpret the results of quantitative analyses using datasets from actual evaluation studies. The early phase of the course will focus on necessary but essential pre-analysis tasks often overlooked in the research training process. These include: identifying and resolving dirty data including logical inconsistencies, and conducting simple and complex data transformations. The second half of the course focuses on conducting bivariate and multivariable statistical tests. This is an applied course, emphasizing skill building through hands-on work using statistical analysis software in each class session.  

Epidemiology II

As a basic science of public health, epidemiology is responsible for the identification of causes of disease that can guide the development of rational public health policies. The accuracy of the information provided by epidemiologic studies is therefore of central concern. Epidemiologic methods are the tools we use to make valid causal arguments. This course builds upon the methods introduced in P6400 Principles of Epidemiology or the Quant core module. The primary objective is to provide students with the basic tools necessary to design, carry out, and interpret the results from observational epidemiologic studies. 

Qualitative Data Analysis 

The collection of qualitative data is widespread and growing in public health research. However, the credibility and quality of qualitative research rests upon utilizing  systemic rigor in collecting, recording, organizing, categorizing, and interpreting qualitative findings. Focusing in particular on focus group data, this course introduces a variety of approaches to qualitative data analysis, with a focus on applying thematic or framework analysis, and facilitates their application and manuscript development through hands-on group work and work outside of class. 

Related Certificates

• Advanced Epidemiology
• Applied Biostatistics
• Comparative Effectiveness Outcomes Research
• Health Promotion Research and Practice

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• BEST Diversity Program
• Columbia Summer Research Institute
• Epidemiology and Population Health Summer Institute at Columbia University  (link is external and opens in a new window)

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Qualitative Methods in Public Health Research

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