Qualitative Methods for Health Research

Judith Green, Nicki Thorogood

• Editore: SAGE Publications Ltd
• Anno: 2018
• ISBN:
  9781526448798
• Edizione: 4
• Argomento: Social Sciences
• Categoria: Social Science Research & Methodology

Packed with practical advice and research quick tips, this book is the perfect companion to your health research project. It not only explains the theory of qualitative health research so you can interpret the studies of others, but also showcases how to approach, start, maintain, and disseminate your own research.

It will help you:

• Understand the role of the researcher
• Develop an effective research proposal
• Seek ethical approval
• Conduct interviews, observational studies, mixed methods, and web-based designs
• Use secondary and digital sources
• Code, manage, and analyse data
• Write up your results

Whether you are studying public health, sports medicine, occupational therapy, nursing, midwifery, or another health discipline, the authors will be your surrogate supervisors and guide you through evaluating or undertaking any type of health research.

Part I Principles and Approaches in Qualitative Health Research

1 Qualitative Methodology in Health Research

The online resources linked to this chapter can be found at https://study.sagepub.com/green_thorogood4e

Chapter Outline

• Chapter summary 3
• Introduction 3
• What is qualitative research? 7
• Qualitative research and ‘evidence-based practice’ 9
• The orientations of qualitative research 12
• Where does qualitative research fit? 17
• Some assumptions about qualitative research 22
• Conclusion 26
• Key points 27
• Exercise 27
• Further resources 27

Chapter summary

This chapter introduces the social science roots of qualitative approaches to research, and outlines the contributions they make to our understanding of health, illness and health care in an era of evidence-based practice. We outline some broad orientations common to qualitative research, discuss how qualitative research fits into health research in general, and assess some of the assumptions that are made about the strengths and weaknesses of qualitative research.

Introduction

Qualitative approaches to health research have their roots in social science and humanities disciplines such as sociology, social anthropology, psychology, history and geography. Maintaining health and dealing with ill health are, and have been, universal challenges for human societies, and the social sciences have contributed greatly to our understanding of how health and illness have been dealt with over time and across different human societies. Health professionals have also had a long history of integrating insights from the social sciences into their understanding of human health (see, e.g., Henderson 1935; Kleinman 1973; Helman 2000). More recently, the methods of social research have been adopted and accepted as part of the toolbox of approaches needed to provide evidence for practitioners and policy-makers across fields such as global health, primary care, health promotion, health services and nursing. Although social sciences and humanities disciplines all have their own distinct methodological and theoretical traditions, what they have in common is a focus on what people do, and why, in the context of social relationships. How do people think about their own health and that of their communities? What do they do to maintain health, or deal with illness? How do health practitioners relate to their patients, and to other professionals? As the challenges for health policy and practice are increasingly recognized as rooted in the ‘social’, it is not surprising that health care practitioners, managers and policy-makers have turned to social enquiry to enhance understanding of health, health behaviour and health services, and to improve the management and provision of services. The range of experiences, behaviours and practices that are relevant to health and health care is vast. Take just one example of a challenge for many health care systems: addressing the rising prevalence of obesity. It is clear that any response will need to take into account the complexity of the ‘causes’ of the problem in order to think about interventions that might help. These range across issues related to individual behaviour (in the amount of food we eat, or exercise we take); those related to the ways in which those ‘behaviours’ are rooted in our cultures and environments, and reproduced over time in social contexts; and the broader conditions which make our individual responses more or less likely: the policies that shape what kinds of food are available to us, or how easy it is to walk rather than drive to work. Social science research also addresses problems like this in a more critical way, asking why and how obesity itself has become seen as ‘a problem’, and why policies tend to be directed at the individual level, not the broader determinants of health.

What do qualitative researchers do?

Qualitative research has a particular role to play in helping us generate useful knowledge about health and illness at a range of levels, from that of individual perceptions through to that of how global systems work. Qualitative methodology includes a set of approaches for answering questions about what happens, why and with what effects at these different levels. The approaches used by qualitative researchers are diverse – and indeed at times contradictory, reflecting their roots in particular disciplines or philosophical traditions. The next chapter introduces some of this diversity, but what unites qualitative approaches is that they are directed largely at understanding more about a phenomenon, rather than measuring it. The phenomena in question could be attitudes, behaviours, concepts (such as ‘obesity’ or ‘health’), organizations, technologies, networks, policies – or indeed almost anything. For instance, if we take the issue of rising levels of obesity in many populations, just a few of the potential topics and research questions that could be addressed using qualitative research include:

• Topics related to individuals’ roles, identities and views (the ‘micro’ level): such as understanding, experiences, interpersonal communication, behaviour, practices:
  • What do people understand by ‘a healthy diet’?
  • What barriers do people face in eating a healthy diet?
  • What are the effects of the stigmatization of obesity on individuals?
• Topics related to social groups (the ‘meso’ level): such as organizations, networks, communities, hospitals:
  • How do the meanings of body size differ across ethnic groups?
  • What happens when new multidisciplinary teams are established in weight loss clinics?
  • How did a school implement a successful healthy food initiative?
• Topics related to the ways in which society is structured (the ‘macro’ level): global networks, inequalities, environments, national policies:
  • What role does the global food industry have in shaping public health policy-making?
  • Do health promotion materials about body weight reproduce gendered social roles?
  • How did obesity emerge as a social problem?

This book is about the methods of qualitative research that can be used to answer these, and many other, questions. We discuss the principles of good research design, the major methods for generating and analysing qualitative data, and the issues raised by doing qualitative research in practice. Qualitative research in practice could be anything from a small interview study undertaken within a few weeks for a student dissertation to a large, multi-country evaluation of a complex intervention that takes several years. The aims are similarly diverse: finding out what patients think of a service; evaluating a policy change; exploring how ideas of medicine use have changed over time. Qualitative researchers themselves also come from many different backgrounds, including sociologists, anthropologists, clinicians and biomedical researchers. We have written this book primarily for health science practitioners and students, who may have little background knowledge of social science but are interested in using or understanding more about qualitative approaches to health research, and for social scientists interested in applying their disciplines to the fields of health, health care and illness.

Research for and research of health

What we mean by ‘health research’ covers two, often rather distinct, strands of work. As suggested in the range of questions one could ask about obesity, some could be seen as critical studies of health from various social science perspectives, which address questions such as: What are health and illness? How are they managed, and in whose interests? Others could be understood as studies for health, from within fields such as public health, health promotion, nursing or health services research, in which the contributions of social science are defined primarily by the health agenda. Studies of health are often from a more critical perspective, in that they aim to explore the concepts and categories that are implicit in the health agenda, whereas studies for health take these concepts and categories as the starting point. Thus, taking our example of research on obesity, Deborah Lupton (2015) analyses health promotion campaigns on obesity as examples of what she calls the ‘pedagogy of disgust’, and critiques the moral and political consequences of the ways in which they stigmatize people who are overweight. This is social science research which addresses health (what it is, how it is understood) as a topic of enquiry. Studies for health have the existing health agenda as their starting point. That is, they tend to ask research questions which have been already formulated from problems in practice or policy. For instance, in a qualitative study of the views about body weight of parents of teenagers, Wendy Wills and Julia Lawton (2015) start by noting that parents have an important role to play in managing health and weight, and that it is important to understand their perspectives in designing interventions for families. Here, the aim of enquiry is not to critique these parental roles, or to question whether intervening is the right thing to do. The distinction between these two sorts of investigation is of course not a clear one: Lupton’s study could inform health promotion strategies, and Wills, Lawton and their colleagues have elsewhere problematized the focus on ‘healthy eating’ given the other concerns parents have about teenage children (see Backett-Milburn et al. 2006). Many applied researchers also take a critical approach, and may well contribute to changing assumptions as well as addressing a predefined problem. Indeed, a key component of qualitative approaches is a critical stance: the issue is the balance between how far the agenda is taken as a starting point. The distinction between studies ‘of’ and studies ‘for’ health also provides a useful way of thinking about the aims of the study. Is it basic research, primarily aiming to expand our knowledge of society, or more applied research, primarily aiming to provide evidence on an existing and defined health care problem? How and where the two kinds of investigation are written up may also differ, in order to meet the needs and expectations of different intended audiences (see Chapter 14).

However, the distinction between ‘critical’ and ‘applied’ studies does not imply different criteria for methodological rigour. Doing applied research for health is not an excuse for inadequate research design, a superficial approach to data collection or under-theorized analysis. Producing useful findings involves, as a necessary condition, producing sound findings. Indeed, if the research has been funded to produce policy-relevant findings, there is perhaps even more reason for ensuring rigorous design and analysis. The principles of qualitative research are, therefore, exactly the same, whether the study is primarily academic (such as a PhD thesis in anthropology) or more ‘applied’, such as a funded evaluation of a health care intervention. Similarly, the same principles of good design and conduct apply whether the research setting is a health service organization in a high-income country, or a rural village in a low-income country. Clearly the practicalities of carrying out the study will differ, but we hope to show how the same elements of research planning are involved. Whatever the setting, and whatever the primary aims of the research, the researcher has to consider the local cultural and social context, and this is an essential part of adapting methodological techniques to a particular research project. Throughout this book we have used examples from a variety of settings, and we hope this range will illustrate the universal applicability of methodological principles.

What is qualitative research?

Health research, then, includes any study addressing understandings of human health, health behaviours and practices, or health services, whatever the disciplinary starting point. We have already suggested that there are some rather different ways of defining what qualitative research is. Many utilize a contrast with quantitative research to distinguish the particular role of qualitative methodology: in terms of the types of data generated, the methods used to generate those data, or the kinds of question asked. Here we explore a little more what is meant by ‘qualitative’ research.

Qualitative data

The most basic way of characterizing qualitative research is by describing the kind of data it generates: that is, the data are usually in the form of words, in contrast to the numbers generated by quantitative research. Some have seen this division between ‘quantitative’ and ‘qualitative’ data as a false one, in that it is perhaps impossible (or at least unhelpful) to characterize data in this way, because all research involves some quantification (however basic) and all research involves some words. Many qualitative studies use simple frequency counts of themes in interview data, for instance, and even categorizing data into themes involves some elementary quantification, to decide whether a data point (such as an interview quote) belongs in a set or not. Similarly, all quantitative data also entail language in some form. But, in general, qualitative research does tend to use and generate language data (written or oral), and quantitative research numerical data.

Qualitative methods and designs

A second way of characterizing qualitative research is by the methods used to generate those data, or design of the study. There are some methods that are particularly associated with qualitative research, primarily various kinds of interview and participant observation. These techniques for generating data are discussed in the chapters in Part II of this book. There are also some designs that are particularly associated with qualitative research, such as ethnographic case studies, whereas others (surveys or experiments) are more associated with quantitative research. However, again, this is not a perfect division. Interviews and observations can also be used in quantitative studies, for instance where responses to questions or behaviours observed are later coded, and counted. In practice, as we discuss below, qualitative research goes on within many different study designs: as part of an evaluation also including a randomized controlled trial (see Chapter 3), or as an element of a quantitative survey, such as analysis of a free text box at the end of a questionnaire.

Qualitative research questions

A third, and perhaps more helpful, distinction between qualitative and quantitative research relates not to the data used, or the study design, but to the overall aims of the study. In essence, qualitative studies seek to understand phenomena, not to quantify them. As in the list above, on possible research related to obesity, qualitative research questions tend to be about the ‘what’, ‘how’ or ‘why’ of a phenomenon, rather than questions about ‘how many’ or ‘how much’. Box 1.1 lists some examples of qualitative research studies reported in social science and biomedical journals, together with the main methods they used, and the stated aims of the study. ...