Overview of Qualitative Research Methods for Primary Care and Public Health

1. Overview of Qualitative Research Methods for Primary Care and Public Health Roberta E. Goldman, PhD Department of Family Medicine Alpert Medical School of Brown University July 2012

2. Qualitative Research Overview • Qualitative research provides data about meaning and context regarding the people and environments of study • Study populations are increasingly alert to how they are being approached by interventionists, and how they are represented in research Roberta Goldman, PH.D., Brown University and HSPH, 2012

3. The Qualitative Perspective “I want to understand the world from your point of view. I want to know what you know in the way you know it. I want to understand the meaning of your experience, to walk in your shoes, to feel things as you feel them, to explain things as you explain them. Will you become my teacher and help me understand?” James P. Spradley (1979) Roberta Goldman, PH.D., Brown University and HSPH, 2012

4. Nature of Qualitative Research • Attempts to “make sense of” the social world in terms of the meanings people bring to it • To uncover ideas, insights, or ways of thinking of and explaining phenomena about which little is known • To gain novel and fresh perspectives on things about which quite a bit is already known Roberta Goldman, PH.D., Brown University and HSPH, 2012

5. Qualitative Research Approach • Differs in approach and results from surveys • Looking for range of phenomena in sample studied • Rarely use statistical analysis • Not representative of the total population • Purposive, stratified samples • Generally not random samples • Multi-method (i.e. multiple qualitative methods; mixed qualitative and quantitative methods) Roberta Goldman, PH.D., Brown University and HSPH, 2012

6. How to Choose your Methods • The methods are in service to your research questions and goals. • The quantity of your interviews, focus groups, or observations is dependent on the participant characteristics you need to include, and the purpose of your research. Roberta Goldman, PH.D., Brown University and HSPH, 2012

7. Uses of Qualitative Research in Primary Care and Public Health • Obtain data that are useful on their own • Detailed, contextually-based data on subtle meanings associated with attitudes, beliefs, and behaviors • What, how, and why people conceptualize issues differently in different contextual circumstances • Generate “indigenous” terms and categories • Generate new avenues for study • Process evaluation Roberta Goldman, PH.D., Brown University and HSPH, 2012

8. Uses of Qualitative Research in Primary Care and Public Health • Obtain data that serve as building blocks or can be triangulated with other data: mixed qualitative/quantitative design • Information that enhances intervention design • Information that informs survey design and implementation • Understand the range of relevant survey questions and responses • Test surveys and intervention elements • Cognitive interviewing and pilot testing • Information that complements and/or explains other results Roberta Goldman, PH.D., Brown University and HSPH, 2012

9. Example: • Hablemos de Tí: Let’s Talk about You (PI: R. Goldman) • Focus groups of middle-aged and older Latinas about perspectives on social, cultural, physical elements of menopausal transition (n=9 groups) • “Reunion” groups (n=9 groups) • Individual interviews (n=18 participants) • Interactive internet intervention (n=81 participants) Roberta Goldman, PH.D., Brown University and HSPH, 2012

10. The Qualitative Study Question • Ask an overall study question that has open-ended possibilities for answers: • What are the emotional experiences of public middle school children who change schools mid-year? • How do Portuguese older adults conceptualize the diabetic diet? • In what ways do culture and religion play a role in Hmong adults’ views of health care? • How do political ads on television influence adults’ perceptions of health care reform? Roberta Goldman, PH.D., Brown University and HSPH, 2012

11. Entering the Community

12. Preparation for Research • Preparatory steps are essential for community-based qualitative research • Define your community • Involve community representatives at all stages from the very beginning • Get involved in the community • Stay involved in the community • Decide how to represent yourself Roberta Goldman, PH.D., Brown University and HSPH, 2012

13. Entering the Community • Learn what you can from previous studies and secondary data sources: • Academic and popular media • Public health and other disciplines • Maps • Demographic statistics • Urban planning documents • Etc. Roberta Goldman, PH.D., Brown University and HSPH, 2012

14. Entering the Community • Learn what you can from knowledgeable individuals: • Community, civic, political, economic, health, education, business, unions, social service, etc. • Academics • Other key informants • Assess the quality of your key informants Roberta Goldman, PH.D., Brown University and HSPH, 2012

15. Entering the Community • Learn what you can through participant observation • e.g. neighborhoods, organizations, resources, businesses, housing, transportation, health sites, educational resources, financial structures, community events • Be able to recognize what people are talking about or alluding to • Recognize relevant social fields for inquiry Roberta Goldman, PH.D., Brown University and HSPH, 2012

16. Selected Qualitative Research Methods • Participant observation • Individual interviews • Focus groups • Media content analysis • Visual (i.e. video or still image) • All in conjunction with broad literature review, including ethnographic literature • The more you know before you start, the better your research will be Roberta Goldman, PH.D., Brown University and HSPH, 2012

17. Participant Observation – More than just hanging around • What is it? • Etic view • Observation • Reflection • Ranges from high to no participation • Informal interviewing for emic explanation Roberta Goldman, PH.D., Brown University and HSPH, 2012

18. Participant Observation • Why do it? • See what’s really going on • Counterbalance: Triangulate data from other methods • Understand and “test” what people say • Know what to ask people about because you’ve seen it already Roberta Goldman, PH.D., Brown University and HSPH, 2012

19. Participant Observation • How to really see: • Know what you’re looking for, and • Be open to seeing what you don’t expect • Be cognizant of what you’re looking at • Observe the details, variations, etc. • Take notes • Reflect on observations and notes; question what you saw • Discuss observations and notes • Go look again • and so on. . . Roberta Goldman, PH.D., Brown University and HSPH, 2012

20. Participant Observation • Spectrum of observation Full participant Passive Observer Roberta Goldman, PH.D., Brown University and HSPH, 2012

21. Participant Observation - Fieldnotes • Document your observations • Fieldnote journal – running record of observations AND observer comments • Structured observation note grid • Brief notations while in the field • Expand upon and organize notes as soon as possible – thick description • Truism in anthropology: • For every hour of observation you need 3 hours of writing fieldnotes Roberta Goldman, PH.D., Brown University and HSPH, 2012

22. Types of Individual Qualitative Interviewing

23. Categories of Individual Qualitative Interviews • *Informal • Conversations in the field • Unstructured • Interview setting with no formal guide • **Semi-structured • Interview setting with an interview guide; probes • Structured • Interview setting with a rigid question list Roberta Goldman, PH.D., Brown University and HSPH, 2012

24. In-Depth Interviews • Various kinds and purposes • Open-ended questions • Looking for meaning and context and information in respondents’ own words • Combine structure with flexibility • Interactive • Follow new lines of inquiry as they arise • Explore a topic in-depth with follow-ups and probes: whys, hows, examples, etc. Roberta Goldman, PH.D., Brown University and HSPH, 2012

25. Key Informant Interviews • Insider/outsider • Know something about your topic area, in a way different from your way of knowing • Can articulate their knowledge • Choose broadly • Can connect you with other KIs and information • Semi-structured using flexible question guide • Maybe informed consent • Usually no monetary compensation • Exploratory; process evaluation; explanatory Roberta Goldman, PH.D., Brown University and HSPH, 2012

26. Life History Interviews • In-depth exploration of a small number of illustrative individual cases • Useful for collecting detailed, contextual, diachronic data • Life history interview goes both backward and forward in time • Places the topic of interest within the context of interviewees’ daily lives, both past, present, and looking into the future Roberta Goldman, PH.D., Brown University and HSPH, 2012

27. Conducting Individual Semi-Structured Interviews • Consider the setting – privacy, comfort, security, noise level, impact of others present, where you put the mic, etc. • Consider your appearance, dress, behavior, demeanor; be tranquil • Introduce yourself, project, sponsor Roberta Goldman, PH.D., Brown University and HSPH, 2012

28. Conducting Individual Semi-Structured Interviews • Informed consent and assurance of confidentiality • Explain process of the interview • Ask permission to record and take notes • Gain rapport – friendly AND professional • Be real, but stay professional and appropriate • Be empathic because you are a human being, but you are not a counselor • Develop strategies to redirect Roberta Goldman, PH.D., Brown University and HSPH, 2012

29. Conducting Individual Semi-Structured Interviews • Always bring a question guide that you know well and have practiced in pilot interviews • Can use guide flexibly in terms of wording and question order • Stay alert for new avenues of inquiry that arise due to participant’s responses • Make quick notes on guide as reminders – started a topic; want to return to a topic • If returning to a question, note that it was discussed before Roberta Goldman, PH.D., Brown University and HSPH, 2012

30. Conducting Individual Qualitative Interviews • Listen alertly; make quick decisions • Do you need a follow-up question? • Do you need a probe? • Is it time to move on to the next question? • Don’t use leading phrasing or paraphrasing • Ask for clarity • Be sure you can explain to someone else what the participant said in the interview; if not, you need clarity from the participant: PROBE • Use a variety of neutral probes Roberta Goldman, PH.D., Brown University and HSPH, 2012

31. Writing Open-Ended Questions

32. Philosophy • Few questions with broad reach or • Many specific questions or • Start broad, get more narrow • Your design of the question guide depends on your goals for the research, your participants, your moderator’s skills, nature of the topics Roberta Goldman, PH.D., Brown University and HSPH, 2012

33. Know why you’re asking questions • Be very familiar with your objectives: know what you want; know what you mean • Write questions to get at content, context and meaning – go for the why’s and when’s and how’s in addition to and maybe more than the what’s • Ask for explanations, feelings, understandings, personal interpretations • Use scripted and/or spontaneous probes Roberta Goldman, PH.D., Brown University and HSPH, 2012

34. It’s an iterative process. . . • Relax, think broadly, then more narrowly • Blitz out your topics • Review, edit topics • Talk to colleagues about topics, edit • Form into open-ended questions • Edit and revise your questions – multiple times! Roberta Goldman, PH.D., Brown University and HSPH, 2012

35. It’s an iterative process. . . • Critique questions for • Quality (are they truly open-ended?) • Impartiality (do they avoid leading phrasing?) • Literacy (are most participants likely to understand the words in the questions and the meaning of the questions?) • Clarity (does the wording of the questions adequately reflect what you intend the questions to ask?) • Assess appropriateness (given your topic and interview setting, will the questions upset your participants – unsettling personal questions, test-like questions, etc?) Roberta Goldman, PH.D., Brown University and HSPH, 2012

36. It’s an iterative process. . . • Review, discuss, edit, refine questions • Consider order and placement • Often start with easy to answer, ‘grand tour’ question • Consider impact of earlier questions on later questions • Show questions to people who are familiar with your objectives and those who are not • Consider the usefulness of every question and delete • Pilot the questions with people similar to your study population – some form of Cognitive Interviewing • Modify and finalize questions • Be willing to revisit question script as study proceeds • Change wording or order; Add/delete questions Roberta Goldman, PH.D., Brown University and HSPH, 2012

37. What to Include in your Question Script • Core questions • Follow-up questions: Specific anticipated questions that follow core question • Probes: Anticipated general probes to ask why, why not, how, when, etc. Roberta Goldman, PH.D., Brown University and HSPH, 2012

38. Here’s the hard part: What will NOT be in your question script • Directions for spontaneously re-ordering questions • Follow-up questions to: • Seek clarification • Seek explanation for unanticipated response • Follow new lines of inquiry that arise due to a previous response This is where the real action lies! Roberta Goldman, PH.D., Brown University and HSPH, 2012

39. Focus Groups

40. What is a Focus Group? “A carefully planned series of discussions designed to obtain perceptions of a defined area of interest in a permissive, non-threatening environment.” Krueger RA, Casey MA. 2000. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Roberta Goldman, PH.D., Brown University and HSPH, 2012

41. Why do Focus Groups? • Focus groups are about human interaction • Benefit from social discourse • Research question lends itself to collecting more superficial data from an interactive group of people • Discussion of ideas, opinions, beliefs, knowledge, preferences, etc. • Not looking for in-depth case histories Roberta Goldman, PH.D., Brown University and HSPH, 2012

42. Other Qualitative Methods • Media content analysis • Visual methods Roberta Goldman, PH.D., Brown University and HSPH, 2012