Qualitative research methodology and evidence-based practice in public health

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9 Qualitative research methodology and evidence-based practice in public health


Pranee Liamputtong



Learning objectives


After studying this chapter, you should be able to:




  • know what qualitative research is about



  • understand the nature of qualitative approach



  • appreciate the value of qualitative research in public health



  • see the relevance of qualitative inquiry in evidence-based practice in health.




The ‘Body and Soul’ program in the Samoan community in Hawaii

Churches have a great capacity to promote overall health and to reach marginalised individuals and communities to reduce their health inequalities. Churches, for Samoan migrants living in the USA, are established, trusted and well-attended organisations which have an ability to address the wellbeing of their community. In this study, Cassell, Braun, Ka’opua, Soa and Nigg (2014) qualitatively examined the adaption of ‘Body and Soul’ (a proven faith-based, health promotion program) for use in Hawaii’s Samoan churches.


The findings from their research showed the value of qualitative research methods to inform the adaptation of evidence-based health promotion programs for communities experiencing health inequalities. Additionally, this research pinpointed possible intervention strategies that could work with other migrants from distinct Pacific Island jurisdictions who experience similar poor health outcomes to Samoan migrants in the USA.


According to Cassell et al., qualitative interviews with Samoan community members helped to reveal ‘underlying socioecological factors’ that significantly contribute to obesogenic trends in Samoans living in Hawaii. These factors included ‘changes in the vocational structure of Samoan society, combined with influences because of migration and acculturation into Western societies, modified cultural norms surrounding the adoption of Westernised diets, and the prominence of Western foods within cultural practices’ (p. 1668). The authors suggest that the use of qualitative approach was an ‘efficient approach’ that assisted in the implementations of health promotion interventions to suit a particular group of people (Cassell et al., 2014).



Introduction



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


(William Bruce Cameron, 1963, cited in Patton, 2015, p. 14)

Due to the shift towards the social model of health care (see Chapter 1 in this volume), public health researchers and practitioners have increasingly become interested in the insider perspectives and experiences of key players in health, including health consumers and healthcare providers (Simmons-Mackie & Lynch, 2013). Thus, qualitative research has been adopted in public health in many ways and in numerous field of health research (Padgett, 2012; Guest, Tolley & Wong, 2013; Liamputtong, 2013a, b). The case study above attests to the increasing adoption of qualitative inquiry in public health.


The main focus of this chapter is on qualitative research. You will learn about the nature of qualitative inquiry and the need for qualitative research in public health. You will also gain a basic understanding of some philosophical assumptions of qualitative research that lead to different understandings about public health in different groups of people.


Attempts have been made in the last few decades to provide more evidence-based public health care to individuals and communities. Thus, we have witnessed a large number of research projects carried out in the public health area and often this involves the use of quantitative methodology including experimental design, epidemiology and systematic reviews of interventions (see Chapter 10 in this volume). But will this research reflect the realities of people? Particularly, what does this mean to people who do not have opportunities to contribute in research that can be used as ‘evidence’ in health care? Evidence-based practice in public health and the need for qualitative inquiry is also discussed in this chapter.



Qualitative inquiry




The first contribution of qualitative inquiry is illuminating meanings and how humans engage in meaning making – in essence, making sense of the world (Patton, 2015, p. 6).


Qualitative research is a form of ‘social inquiry’ that attempts to understand how individuals construct meaning about the world in which they reside (Holloway & Wheeler, 2010). Hence, qualitative research attempts to interpret the ‘meaning making process’ that people do in their every day life (Patton, 2015, p. 6), and this includes how people make sense of their health and illness (Braun & Clarke, 2013; Liamputtong, 2013a, b). In the social world, we deal with the subjective experiences of human beings, and our ‘understanding of reality can change over time and in different social contexts’ (Dew, 2007, p. 434). Qualitative inquiry examines realities that have an impact on the life, health and wellbeing of individuals or groups in a particular socio-cultural context (Mills & Birks, 2014).




Qualitative research

a form of inquiry that attempts to understand how individuals construct meaning about the world in which they reside.


Denzin and Lincoln (2011, p. 8) point out that the word ‘qualitative research’ has its emphasis on ‘the qualities of entities and on processes and meanings that are not experimentally examined or measured in terms of quantity, amount, intensity, or frequency’. Qualitative research aims to provide answers about the ‘what’, ‘why’ and ‘how’ of a reality, instead of questions about ‘how many’, ‘how often’, or ‘how much’ (Bourgeault, Dinvwall & de Vries, 2010; Green & Thorogood, 2014). Qualitative research relies heavily on words or stories that people tell us (Braun & Clarke, 2013; Liamputtong 2013a, b). Typically, qualitative data appears in the form of written or spoken language as well as images (Guest et al., 2013). Importantly, qualitative research is not used for testing hypotheses, and it does not aim for generalisation and replication. Data generated from qualitative research can be only interpreted within the contexts that the research is undertaken (Braun & Clarke, 2013). For most qualitative researchers, it is accepted that in order to understand people’s behaviour we must attempt to understand the meanings and interpretations that people give to their experiences. Because of the interpretive and flexible approach, qualitative research can provide answers to health issues that other methods cannot ‘reach’, particularly questions which are not responsive to quantitative measurement (Pope & May, 2006; Bourgeault et al., 2010).



Spotlight 9.1 Drugs and alcohol addiction and mental illness among young Russian migrants in Germany

It has been reported that young Russian-speaking migrants in Germany have particularly strong patterns of alcohol and drug consumption. As such, they have a high risk of drug-associated diseases. However, they are also a group that tend to under-utilise existing health services. Flick (2015) and the research team wished to learn about how Russian-speaking migrants see their use of substance and their views about possible consequent diseases, such as hepatitis, and how they deal with them. They are also particularly interested in conditions of the utilisation of health care, and their expectations and experiences, and why they do not utilise it. Therefore, Flick and his research team examined the issues by using qualitative approach.




Question


In your opinion, why should qualitative research be used for such a study?



The nature of qualitative research



Epistemology


Qualitative research is situated within the epistemology of constructivism. Epistemology focuses on the nature of knowledge and the way knowledge is obtained (Bryman 2012; Grbich 2013; Hathcoat & Nicholas, 2014). In public health, we ask what type of knowledge we need to have and whether our research can be done in the same way as those in the natural sciences (such as physics and chemistry) do.




Constructivism

an epistemology that suggests that ‘reality’ is socially constructed. Constructivism rejects the ideal of a single truth. Instead, it argues that there are multiple truths, which are individually constructed.


Epistemology

the nature of knowledge and how knowledge is obtained.


Constructivism posits that ‘reality’ is socially constructed (Hershberg, 2014). Constructivism reject the ideal of a single truth. Instead, constructivism argues that there are multiple truths, which are individually constructed (Lincoln, Lynham & Guba 2011; Grbich, 2013). Reality is seen as being shaped by social factors such as social class, gender, age, ethnicity and culture (Grbich, 2007, 2013). Within this epistemology, it is accepted that research is a very subjective process and this is due to the active involvement of the researcher in the construction and conduct of the research (Lincoln et al., 2011; Grbich, 2013; Hershberg, 2014). According to Grbich (2007, p. 8), research situated within this epistemology emphasises ‘exploration of the way people interpret and make sense of their experiences in the worlds in which they live, and how the contexts of events and situations and the placement of these within wider social environments have impacted on constructed understanding’.


Constructivist researchers believe that when the social world is examined, it needs a different kind of research process than those researchers use in natural sciences. Bryman (2012, p. 28) contends that constructivist researchers need the kind of research ‘that reflects the distinctiveness of humans as against the natural order’. Within this constructivism, it requires the researchers to ‘grasp the subjective meaning of social action’ (p. 30). It is crucial then that a research approach that would allow people to articulate the meanings of their social realities is adopted. Essentially, this necessitates the use of a qualitative inquiry.



Methodological frameworks and qualitative methods


Qualitative research is also situated within several methodological frameworks (Creswell, 2013; Liamputtong, 2013a; Flick, 2015). A methodological framework provides means for seeing in the conduct of qualitative research. In my own writing, I include several salient methodological frameworks, including ethnography, phenomenology, symbolic interactionism, hermeneutics, feminism and postmodernism (see Liamputtong, 2013a). However, Creswell (2013) suggests five traditions including narrative research, grounded theory, phenomenology, ethnography and case study as a methodological framework in qualitative research. Each methodological framework offers different understandings and assumptions about people’s worldview and behaviour. As such, each methodological framework advocates the use of different qualitative methods that researchers use to collect data (Flick, 2015). It must be noted that every methodological framework will be more appropriate for some research questions than others. It is the task of qualitative researchers to consider carefully which theory is more useful and suitable for their research projects.




Methodological framework

a framework used as a means to select suitable methods in qualitative research.


Method

a technique used in collecting data.


Qualitative research has a number of data collection methods. These include the in-depth interview, focus group interview, oral/life history interview, memory-work, participatory action research and ethnographic method. Among qualitative research methods, in-depth interviewing is the most commonly known and is widely employed by qualitative researchers (Guest et al., 2013). Recently, we have also witnessed the emergence of more innovative and participatory qualitative methods such as drawing, photovoice, photo elicitation, diary, digital story-telling and internet methods (Liamputtong, 2007, 2010, 2013a). Each method contains its own salient features, advantages and limitations. Researchers need to select a method or procedures that suit their research as well as the needs of research participants.


Despite differences in methodological framework and methods, Patton (2015, pp. 12–13) suggests that qualitative inquiry contributes to the generation of knowledge in several ways:




  • It reveals meanings that people have.



  • It captures stories so that individuals’ perspectives and experiences can be understood.



  • It examines how things work.



  • It illuminates how systems work and their consequences for the lives of people.



  • It often allows researchers to identify unanticipated consequences which will help researchers to have a better understanding about the individuals.



  • Contextual sensitivity is the essence of qualitative inquiry. It helps researchers to understand the context of those who participate in their research.



Spotlight 9.2 Thai women living with breast cancer

Being diagnosed with breast cancer can be a traumatic experience for many women, generating a number of emotional responses such as despair, uncertainty, anxiety, fear and hopelessness. Liamputtong and Suwankhong (2015) attempted to have an in-depth understanding about the lived experience of Thai women with breast cancer. They conducted in-depth interviews with a number of women who have experienced breast cancer. They also invited the women to provide some drawings about their experiences.


The authors found that while the Thai women in this study sought help from the extraordinary therapeutic landscape of biomedical treatment, they experienced horrendous side effects to survive. These modern treatments, most often chemotherapy and radiation, generated a profound realisation that their body had transformed into ‘a site of illness’. This realisation prompted the women to have an intense motivation for regaining good health and healing, thus transforming their body into a landscape of ‘healing and recovery’. The transformation of the therapeutic landscape of the body was performed mainly through the changes of diet, exercise and living conditions in their daily lives. The authors found that the home and community constitute therapeutic landscapes of emotional wellbeing and healing in the form of social support. Social support played a major role in helping the women deal with their breast cancer. One important aspect of therapeutic landscapes is the cultural landscape. This cultural space constitutes both the everyday and the extraordinary therapeutic landscapes. Within the cultural landscape, cultural beliefs and religious/spiritual practices were of particular importance. It has been affirmed that the connections between cultural beliefs/spiritual practices and places are crucial for healing and recovery. The women in this study adopted cultural beliefs and religious/spiritual practices commonly performed in their locality to be their therapeutic landscapes for dealing with breast cancer. These findings indicate the importance of the emotional aspect of therapeutic landscapes on the lived experience of women living with breast cancer (Liamputong & Suwankhong, 2015).




Questions


1 What is your understanding about qualitative research?



2 From this case study, what can you say about the nature of qualitative research?



3 Can this case study contribute to knowledge regarding breast cancer and women, and evidence-based practice in public health? How?



Why qualitative research in public health?


In the past decade or so, qualitative research has been gradually accepted as a crucial component in our understanding of health. In many areas of public health, researchers have argued for the value of interpretive data. Qualitative inquiry is now also perceived as a crucial means for the planning and provision of health services as well as management of health care (Bourgeault et al., 2010; Green & Thorogood, 2014). Qualitative health research has given rise to critical public health innovations, such as patient-centred care and evidence-based decision-making (Sandelowski, 2004; Grypdonck, 2006; Bourgeault et al., 2010; see also section below).


In public health, it is important to have ‘knowledge that is relevant, not knowledge that is disengaged’ (Packer, 2011, p. 7). As qualitative research attempts to make sense of how the world (including health and illness) is understood and experienced from the perspective of individuals and groups (Bourgeault et al., 2010; Braun & Clarke, 2013; Liamputtong, 2013a; Green & Thorogood, 2014), it allows researchers and practitioners to find knowledge which is relevant to our consumers and our practices. Qualitative inquiry is extremely valuable for public health practice in this regard (Padgett, 2012; Leko, 2014; Baum, 2015). According to Patton (2015, p. 8), by asking deeper questions about what is really happening and making further inquiries into assumptions about why things are occurring, qualitative researchers contribute to knowledge about what works, what does not work, and why.


The ‘new public health’ framework recognises the need to ‘understand’ people (Padgett, 2012; Baum, 2015; see also Chapter 1 in this volume). Thus, it recognises the value of interpretive data that qualitative research can offer. Baum (2008, p. 180), for example, argued for the need for qualitative research in public health, since it ‘offers considerable strength in understanding and interpreting complexities’ of human behaviour and health issues. Qualitative research is crucial ‘for coping with complexity and naturalistic settings’. Due to its flexibility and fluidity, qualitative approach is more suited to understanding the meanings, interpretations and subjective experiences of health and illness of individuals than is the quantitative research (Liamputtong 2013a, b). Importantly, qualitative enquiry allows public health researchers to hear the voices of those who are more marginalised in society (Liamputtong, 2007; Braun & Clarke, 2013). The in-depth nature of qualitative methods allows the participants to express their feelings and experiences of health and illness in their own words (Bourgeault et al., 2010; Padgett 2012; Liamputtong 2013a, b; Green & Thorogood, 2014).




Quantitative research

research that focus on numbers in data collection and statistics in analysis. Its focus is on the testing of theories and it examines findings that can be generalised to the wider population.


Most research in public health tends to be undertaken using quantitative methods (see Chapter 10). Baum (2015) argues that quantitative research can be very useful in explaining public health issues, especially the cause and extent of disease. However, quantitative data may mask people’s experience and their interactions with others. Quantitative data have less power to allow an in-depth understanding of the contextual issues that have in recent times become a major concern in public health. On the other hand, qualitative research offers unrestricted explorations that can assist researchers to discover unanticipated findings or means for further investigation (Leko, 2014; Patton, 2015; Strauss & Corbin, 2015). Essentially, qualitative inquiry is crucial when we attempt to ‘understand enduring challenges and issues that are multifaceted and complex’ (Leko, 2014: 276) that we tend to confront within public health (Bourgeault et al., 2010). Patton (2015, p. 179) puts it clearly that the qualitative approach can ‘show the human faces behind the numbers’, and provide ‘critical context when interpreting statistical outcomes’ as well as make sure that ‘the numbers can be understood as representing meaningful changes in the lives of real people’.


Within the new public health arena, Baum (2015) suggests that qualitative research is useful in many ways:




  • It can explain the economic, political, social and cultural factors that influence health and illness in more depth than through quantitative methods



  • It helps to gain an understanding of how individuals and communities interpret health and illness and make sense of their experiences of illness



  • It enables public health researchers to elaborate on causal explanations and provide contextual data to explain their epidemiological and clinical research.


As such, public health researchers undertake qualitative research for several reasons. Qualitative research is particularly essential when we have little knowledge about health and illness of individuals and communities. It is needed when there is a health problem or issue that needs to be explored. This exploration will in turn allow us to hear more silenced voices. Qualitative inquiry is essential when we need to understand a complex issue associated with health and illness in greater detail. This type of research is carried out when we wish to empower people to have more control of their health and illnesses. Qualitative researchers undertake qualitative research because there is a need to understand the contexts that play crucial roles in the health and wellbeing of the research participants. Qualitative inquiry is crucial when there is a need to develop theories that help to explain and capture the complexity of the problems of certain individuals or population groups that existing theories do not adequately explain. Qualitative research is also used because quantitative measures and statistical analyses cannot provide crucial answers when the uniqueness of an individual is important.


Apr 1, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Qualitative research methodology and evidence-based practice in public health

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