Qualitative methods in public health

1. Qualitative methods in publichealth Mette Sagbakken Department of General Practice and communitymedicine Institute of Health and Society

3. "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 becausehealth professionals and policy makers do not study the whole picture”~ Sagbakken, (1966- AC)

4. Qualitative versus quantitativemethods Prior to establishment ofdisciplines as anthropology, epidemiology – healthprojectsoftencombinedmethods Panum: investigatedmeaslesoutbreak in theFaroe Islands in 1846 – combinedobservations and syrveys Virchow: investigatedtyphusepidemic in 1848 – clinical, pathological, epidemiological, anthropological findings Documentedconcrete links betweensocialconditions and diseases Trostle J. (2005). Epidemiology and culture. Cambridge University Press.

5. Qualitative versus quantitativemethods 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

6. Qualitative versus quantitativemethods “Not everything that can be counted counts, and not everything that counts can be counted.” Albert Einstein (1879-1955)

7. Whatknowledge ”counts”? Manytuberculosis (TB) patients do not completetreatment. Howmany? (quantitative) Why? (qualitative) Many TB patientsuseseveralmonths to getthe right diagnosis. Howmany (quantitative)? Why? (qualitative) Predefinedcategories – a ”shot-gun” method? (Becker) Strengthofqualitativemethods – show how a multitudeoffactorsmayact as causes

8. Whatknowledge ”counts”? • Differentmethodsimportant– can play complementary roles • Ex: Qualitativemethodshelpexplainmortality rates (men, thirdclass passengers) in Titanic by exploringsocial and culturalrules • Social ruleaboutclassimpliedhigher status passengers saved at theexpenseoflower-status passengers • Cultural ruleoflifeboataccesscaused more • men to die (withineconomic status group) Trostle J. (2005). Epidemiology and culture. Cambridge University Press.

9. Qualitative versus quantitative methods Whichresearchmethod? Dependsonthequestion Quantitative methods:Suitable for questionssuch as: ”Howmany…?”, ”Howoften ...?”, or ”Is X more efficientthan Y in treating Z?” Qualitative methods: Suitable for questionssuch as: ”How do peopleperceive…?”, ”What do people do?”, or ”How do peopleexperience ...?”

10. Qualitativemethods • The aimofqualitativeresearch is not to measure or predict, but to gainnewknowledge/understandingofphenomenasuch as: • Human experience, beliefs, behaviour, interaction • Social practices, systems, cultural norms • Involves collection of data not easily reduced to numbers

11. 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?

12. Qualitative methods Identifyprocesses Treatmentinterruption Accumulatedburdens/costs - tipping point

13. Qualitativemethods.. 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)

14. Qualitativemethods Throughexplorationofmeaningnew and unexpectedcategoriesofmeaning and experiencecan be discovered – ….thatdid not fitthe original puzzle

15. Qualitative methods Outcomesmay have multiple causes Important to get an overview over causes – and howtheymayinterrelate

16. Qualitative methods • By identifyprocesses and multiple causes – create time- and context sensitive approaches to diseaseprevention and control: • By identifying multiple causes – increaseawarenessoftheneedof linking multiple actors/sectors/projects (food programs, labourorganizations) • Through a dialoguewiththoseconcerned : - discoverprocesses and experiencespeoplegothroughbeing ill - identifylocalbarriers and enablers - identifyexisting or non-existent support structures - helpidentifymutiple and more sustainablesolutions (beyondbio-med)

17. Qualitative data collectionmethods

18. Data collection methods Interviews • Individual interviews • Semi-structured • In-depth • Informal conversations • Group interviews • Focus groups

19. Data collection methods 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

20. Data collection methods Focus groups – advantages Study interaction patterns Identify issues to include in subsequent individual interviews Validate findings from individual interviews Generate new meaning – several minds work together More data in less time Focus groups – challenges Learn what people say they do, not what they actually do Some may dominate–consensus reached on wrong premises Less suitable for sensitive topics

21. Data collection methods Observation Participant or non-participant “Fieldwork”

22. Data collection methods Observation – advantages • Behaviour/statementsbetterunderstood in lightofcontext • Move beyond the selective perceptions of others • Discoverissuesnoone has paidattention to (tacitknowledge) • Learnaboutissuespeoplearereluctant to talk about • Insightintoprocesses/ chronologiesofevents • Understand complextopics Observation - challenges • To whatextent, in whatwayareyouinfluencingthefield? • Is whatyou ”see” what is really happening? • Should know thelocallanguage • Time consuming

23. Data collection in qualitative methods Study of texts and documents • Documents, books, articles, reports, advertisements, newspapers, diaries • Adds important contextual information – understanding findings