Chapter 1
Invitation to Explore

Objectives:

• To introduce researchers to qualitative methods in public health research, including those whose training and experience may be predominantly in quantitative methods
• To describe the basic characteristics of a qualitative research approach
• To show how qualitative methods can shed new light on complex questions in public health
• To highlight the aspects of qualitative research methodology presented in this book, including content new to this second edition

WHY DO SOME PROGRAMS succeed and others fail? Why are screening programs underused? Why does chronic disease go untreated? Why do countless couples know how to protect themselves from sexually transmitted infection but do not do so? How does a community mobilize itself to solve a persistent health problem? Questions like these may be all too familiar to readers of this field guide-public health practitioners, researchers, and program planners, many of whom have worked for years to protect health and prevent disease in highly vulnerable populations.

Advances in the biomedical and population sciences have brought the means to better health within reach of people around the world. Yet, evidence of escalating disease and inadequate health systems and resources in many countries tell us that there is still much we do not know. How do women and men understand and actually use the technical information they receive to make critical decisions that affect their lives and their children's lives? By opening windows on cultural understandings of health and disease, methods of qualitative research can help us comprehend some of these old problems in new ways.

Our Purpose

The purpose of this book is to make the methods of qualitative science more accessible to researchers and practitioners challenged by problems that affect the public's health. Qualitative design can help us understand the underlying behaviors, attitudes, and perceptions that determine health outcomes; it can identify the social, programmatic, and structural impediments to use of existing services; and it can shed light on how to design new development interventions so they align with the socioeconomic realities of their intended beneficiaries and therefore have a greater potential for success.

We write not only for the qualitative researcher but also for applied social scientists, epidemiologists, health providers, health educators, program managers, and others whose training and experience may be predominantly in quantitative methods. Our readers will be students as well as professionals looking for ways to probe more deeply the whys and hows of questions they may partially have answered in terms of how much and how many. They will want to know what qualitative methods can offer to improve their practice or strengthen their research findings. And many of our readers will be training others to ask the same kinds of questions, to listen, and to observe.

Numerous disciplines have contributed to the phenomenal growth of public health research and practice. Sociology, anthropology, psychology, economics, demography, environmental science, medical geography, medicine, and nursing, among others, have brought their unique perspectives and methods to a multidisciplinary understanding of health and wellness. Parallel advances in these disciplines have resulted in different ways of conceptualizing and addressing issues as diverse as health decision making, health promotion, health systems strengthening, child survival, compliance, substance abuse, adolescent sexuality, domestic violence, and gender relations. Similar progress in service delivery research and evaluation has given us a broader understanding of providers' knowledge and values, client-provider communication, and issues related to the accessibility and quality of health care for populations at risk.

Much of this work has focused on objective questions, such as numbers of births, patterns of illegal drug use, trends in disease prevalence, and numerous factors that predict health behavioral outcomes. Research designs traditionally have been quantitative, describing measurable phenomena, projecting trends, and sometimes discovering causal relationships. Psychological research in health behavior has developed primarily from a quantitative perspective, contributing useful rating scales and behavioral indicators, along with case study methods and tools for observation. Anthropologists and qualitative sociologists have approached some of the same problems from different perspectives, focusing on cultural norms and relationships that influence how people interact and act on everyday experiences (Bernard, 1995; Knodel, 1997). Their methods rely primarily on techniques of observation, participation, guided discussion, in-depth interviewing, life histories, and secondary analysis of documentary data. Emerging methods increasingly used in qualitative research include network analysis and geo-health mapping, using innovative technologies such as data visualization applications and mobile data collection tools.

To conduct rigorous research, investigators must use an appropriate study design, data collection methods, and analytic procedures. Yet there is much overlap among different disciplinary approaches. Quantitative researchers at times use qualitative methods to guide a sampling design or to develop a sensitive data collection tool. Anthropologists and qualitative sociologists turn to quantitative methods when they want to describe a population or measure some tendency they may have observed qualitatively. Quantitative research with representative samples can produce hard, factual, reliable outcome data that usually are generalizable to wider populations (Steckler, McLeroy, Goodman, Bird, & McCormick, 1992). But most quantitative studies lack contextual detail and reflect a limited range of responses (Carey, 1993). On the other hand, qualitative methods elicit rich, contextual data, but their small samples and flexible design usually are not appropriate if the study objective is to describe larger populations with statistical accuracy (Patton, 2002). As a result, researchers have increasingly adopted creative new ways to combine techniques in a research design (Creswell, Klassen, Plano Clark, & Smith, 2011; Teddlie & Tashakkori, 2009), letting the strengths of one method compensate for the limitations of another to yield a more powerful methodology.

We have written this guide not to promote one methodology over another, but because many quantitatively trained health professionals, policymakers, and researchers are looking for ways to expand their methodological options with new tools for answering difficult questions.

In searching the literature on qualitative research, we found it divided between manuals that summarize specific techniques for designing and conducting health-related studies (Campbell, 1999; Hudelson, 1994; Yoddumnern, Mahidon, & Sangkhom, 1993) and more comprehensive texts for general academic audiences (Denzin & Lincoln, 2005, 2011; Guest, Namey, & Mitchell, 2012; Patton, 2002; Rossman & Rallis, 1998). Missing from most manuals was a theoretical basis for qualitative decisions, and few texts included strategies to address practical health research issues and problems that arise in the field. Nor did we find clear guidelines for dealing with the large volume of transcripts that qualitative data collection on sensitive topics often generates. Another gap in the literature was the lack of direction for writing and disseminating qualitative results. Our intent, therefore, is to show first how qualitative methods can shed new light on perplexing questions and, second, to provide basic skills to design, conduct, and disseminate the research.

This volume presents practical strategies and methods for using qualitative research, along with the basic logic and rationale for qualitative research decisions. The guide makes researchers aware of the complexities, advantages, and limitations of qualitative research. Its eight chapters cover a wide range of topics and guide readers through every phase of research-from defining the language and logic of qualitative research, to study design, to the collection, analysis, interpretation, reporting, and dissemination of data.

What Is Qualitative Research?

A challenge to the author of any book on qualitative research is to answer the common sense question: What is it? Although there is no short, comprehensive definition, the unique organizing framework is a theoretical and methodological focus on complex relations between (1) personal and social meanings, (2) individual and cultural practices, and (3) the material environment or context. Similarly, there is no universal blueprint for doing qualitative research, but some basic concepts and principles, described next and summarized in Box 1.1, are common in most qualitative research approaches.

Box 1.1: Characteristics of Qualitative Research

• Explores and discovers
• Seeks depth of understanding
• Views social phenomena holistically
• Provides insight into the meanings of decisions and actions
• Asks why, how, and under what circumstance things occur
• Uses interpretive and other open-ended methods
• Is iterative rather than fixed
• Is emergent rather than prestructured
• Involves respondents as active participants rather than as subjects
• Defines the investigator as an instrument in the research process

1. Qualitative...