Cover Page

QUALITATIVE METHODS IN PUBLIC HEALTH

A Field Guide for Applied Research

Second Edition

ELIZABETH E. TOLLEY
PRISCILLA R. ULIN
NATASHA MACK
ELIZABETH T. ROBINSON
STACEY M. SUCCOP

 

Title Page

Dedicated to Andy Pasternack—our Jossey-Bass editor whose vision and encouragement inspired the first edition of this book.

List of Figures, Tables, and Boxes

Figures

  1. Figure 7.1 Strategic Communications Plan
  2. Figure 7.2 Flyer Disseminating Results from the LinCS 2 Durham Study to the Community

Tables

  1. Table 2.1 Three Paradigms for Public Health Research
  2. Table 3.1 Common Elements of a Research Proposal
  3. Table 3.2 Summary of Sampling Approaches
  4. Table 3.3 Structural Differences in Qualitative Data Collection
  5. Table 7.1 Community Dissemination Formats and Audiences for the LinCS 2 Durham HIV Prevention Study

Boxes

  1. Box 1.1 Characteristics of Qualitative Research
  2. Box 2.1 Checklist for Evaluating Substantive Theory
  3. Box 2.2 Social Ecological Model and the Position of Substantive Theories Along Concentric Levels of Aggregation
  4. Box 3.1 Conceptual Framework: Social Drivers of Adoption of Improved Cook Stoves
  5. Box 3.2 Common Ways to Mix Methodologies
  6. Box 3.3 Priority-Sequence Model: Decisions for Integrating Methods
  7. Box 3.4 Some Federal Requirements for Informed Consent
  8. Box 4.1 Guidance for Conducting Direct Observations
  9. Box 4.2 Using Participant Observation to Identify Recruitment Sites at Bars and Other Establishments for an HIV-Prevention Clinical Trial With Women
  10. Box 4.3 Suggestions for How to Write Field Notes From Participant Observations
  11. Box 4.4 Process for Constructing a Semi-Structured Question Guide
  12. Box 4.5 Types of Qualitative Research Questions
  13. Box 4.6 Levels of Interview Questions in a Qualitative Study of Emergency Contraception (EC)
  14. Box 4.7 Deciding How Many Focus Groups to Conduct
  15. Box 4.8 Collecting Background Information From Interview and Focus Group Participants
  16. Box 4.9 Characteristics of a Good Interviewer or Moderator
  17. Box 4.10 Common Errors in Focus Group Moderating
  18. Box 4.11 Steps to Conducting a Focus Group
  19. Box 5.1 Developing a Risk Management Plan
  20. Box 5.2 Technology and Qualitative Research
  21. Box 5.3 Illustrative Budget Considerations
  22. Box 6.1 Qualitative Data Analysis: Step by Step
  23. Box 6.2 Noting Content in Transcripts: An Excerpt From an Interview With a Peer Educator and Sex Worker
  24. Box 6.3 Transcript Excerpt and Emergent Codes
  25. Box 6.4 Preliminary Codebook
  26. Box 6.5 Application of the Code “Conflict” by Two Coders
  27. Box 6.6 Qualitative Intercoder Reliability Matrix
  28. Box 6.7 What to Look for in Software for Qualitative Data Analysis
  29. Box 6.8 Coding Report on Conflict
  30. Box 6.9 Memo on Sexual Behavior
  31. Box 6.10 Data Reduction Matrix Based on Sexual Behavior Coding Report
  32. Box 6.11 Using a Diagram to Organize Findings
  33. Box 7.1 Ways to Foster Two-Way Communication in Research
  34. Box 7.2 Checklist: Elements of an Effective Communication and Dissemination Plan
  35. Box 7.3 Working With the Media
  36. Box 7.4 Using Social Media to Share Research
  37. Box 7.5 How to Make Study Findings Accessible
  38. Box 7.6 Dissemination Factors That Promote Utilization
  39. Box 7.7 Policy Dissemination Tips
  40. Box 8.1 How to Organize a Standard Scientific Article or Report
  41. Box 8.2 Content Checklist: What to Include in Study Write-Ups
  42. Box 8.3 How to Organize and Report Findings From Mixed-Method Studies
  43. Box 8.4 Does Your Study Matter?

List of Case Studies

  1. Case study 1: Prevent: Human— Animal Exposure Study
  2. Case study 2: Engaging Male Partners in Women's Microbicide Use
  3. Case study 3: LinCS 2 Durham: Linking Communities and Scientists to Durham HIV Prevention
  4. Case study 4: Sustained Acceptability of Vaginal Microbicides
  5. Case study 5: Adolescent Women and Microbicide Trials: Assessing Challenges and Opportunities to Their Participation
  6. Case study 6: A Field Assessment of Adoption of Improved Cook Stove Practices: Focus on Structural Drivers
  7. Case study 7: Exploring Gender-Based Violence Among Men Who Have Sex with Men, Male Sex Workers, and Transgender Communities
  8. Case study 8: Sociobehavioral Research and Community Planning to Develop Site-Specific Plans for PrEP Rollout
  9. Case study 9: Evaluation of Malawi Male Motivator Intervention
  10. Case study 10: Reasons for Contraceptive Nonuse in Rwanda
  11. Case study 11: Personal Involvement of Young People in HIV Prevention Campaign Messages: The Role of Message Format, Culture, and Gender
  12. Case study 12: Voluntary Medical Male Circumcision in Kenya
  13. Case study 13: Alive & Thrive
  14. Case study 14: Communicating About Microbicides with Women in Mind

Foreword

For the past 10 years, I have taught an introductory course to master of public health (MPH) students using the first edition of Qualitative Methods in Public Health: A Field Guide for Applied Research (Ulin, Robinson, and Tolley, 2005). It has been an invaluable guide for students eager to understand how and why things work the way they do. The new edition continues that approach. It gives students a solid grounding in the methods of inquiry into the anatomy of a public health problem, teaching them to explore beneath the surface and discover why a problem exists as well as what the practitioner can do to address the problem.

Now in this new edition, examples have been updated and broadened to speak to greater diversity in the public health field. We see in the new material how the field is growing and how research methods have kept pace with new concepts and challenges. Qualitative research methods have found a footing in applied public health, with funding agencies now expecting to see many proposals incorporate a qualitative component in the development, implementation, or evaluation of public health interventions. The second edition takes the reader beyond evaluation of public health interventions and goes directly to research for change. Inequities in power and privilege must be addressed by actively seeking participation of neglected voices, such as women and minorities. Vivid illustrations show how research participants become potential change agents if they have been included in the conduct of the research. This is a bold new approach accompanied by research techniques for making it happen, including more emphasis on the value of mixed methods and on participatory design in which community members actually become partners in the research process.

Readers inexperienced in qualitative research will welcome the clear steps outlined in the chapter on methods, expanded in this edition. They will also discover the utility of mobile devices such as tablets for data collection and consider greater linkages between individual, organizational, and institutional behavior as well as more ambitious goals related to health systems strengthening, health security, human rights, and health equity. The new edition also places more emphasis on qualitative analysis software and on writing for journals, a discussion that seasoned researchers as well as students will find useful.

Given greater recognition today of what qualitative research methods can do to help us understand and solve public health challenges, this book will have a wide audience. Examples in the text cut across problems encountered in public health, community medicine, and social science practice in many parts of the world. Common to all of these is the need for practical, down-to-earth advice on how to apply the methods of qualitative research to real-world settings. Numerous case studies and examples throughout the text and in the appendices provide practical guidance on many aspects of research that conventional text books often neglect, such as developing consent forms, managing budgets, designing interview guides, working with field assistants, and training data collectors.

Taken as a whole, the book represents an accumulation of experience and guidance from researchers who have been using these methods in applied public health work in global and domestic settings for many years. They share their wisdom and insight with readers, helping both to raise excitement about the possibilities these methods offer, and to reassure new researchers who may be considering qualitative methods for the first time.

Suzanne Maman, MHS, PhD
University of North Carolina at Chapel Hill

Reference

  1. Ulin, P. R., Robinson, E. T., & Tolley, E. E. (2005). Qualitative Methods in Public Health: A Field Guide for Applied Research. 1st ed. San Francisco, CA: Jossey-Bass.

Acknowledgments

Many individuals had a hand in bringing this second edition of Qualitative Methods in Public Health from plan to press.

There is also history to acknowledge, for a second edition cannot happen without a first edition. We reiterate our thanks to those who helped make that first edition a reality: those at the U.S. Agency for International Development (USAID), who provided both financial support and substantive guidance on the content of the guide, especially Sarah Harbison and the late Erin T. McNeill. We also thank other individuals at FHI 360 (then Family Health International)—particularly Cynthia Woodsong, as well as colleagues at the World Health Organization, the Population Council, and organizations beyond who contributed their assistance, insight, materials, and support. FHI 360 senior management and Cynthia Geary, formerly of FHI 360, saw us through both editions of this book; to them we are further indebted.

We also acknowledge the many program and research staff members at FHI 360 who have shared research materials and stories about what has worked well and not so well when conducting qualitative research in the field. In particular, we offer special thanks to Kathleen MacQueen for contributing the content on qualitative data analysis software. We also thank the contributors of the case studies, a new feature of this second edition: Jean Baker, Aurelie Brunie, Christine Demmelmaier, Natalie Eley, Emily Evens, Cindy Geary, Nemat Hajeebhoy, Michele Lanham, Kathleen MacQueen, Dominick Shattuck, Rose Wilcher, Christina Wong, and Susan Zimicki. Many thanks also to Paul Feldblum, Michele Lanham, Marguerite Marlow, Emily Namey, the Palladium Group, Sonke Gender Justice, and Christina Wong for their contributions to the appendices. We also thank Denise Todloski at the MEASURE Evaluation project at the University of North Carolina at Chapel Hill for designing many of the graphics in this edition.

We owe a debt of gratitude to Allison Pack, Frances McVay, Seth Zisette, and Amy Mills for assisting us with the complex task of attending to the completeness, accuracy, and organization of the references. As for reviewers both known to us (e.g., Marga Eichleay and Allison Pack for Chapter 6) and anonymous, their feedback has helped us to rethink, reword, and reorganize each of the chapters for the betterment of the entire book. And of course, without the support and excellence of Seth Schwartz, Melinda Noack, and Maria Sunny of Wiley, our collective efforts would never have made it to print.

Last, we thank our families for serving as sounding boards and comic relief throughout the process: Mark, Elise, and Kyle Healy; Don and Marjorie Ulin; Solana Mack and Zorro; and Alan Dehmer.

About the Authors

Elizabeth (Betsy) E. Tolley is a senior scientist and Director of the Social and Behavioral Health Sciences division of FHI 360. Since joining Family Health International (now FHI 360) in 1994, Betsy has used qualitative and mixed-methods research to examine acceptability and use of various sexual health, contraceptive, and reproductive behaviors, including new technologies such as microbicides or development of a longer-acting injectable contraceptive, and existing technologies like implants and intra-uterine devices (IUD). An important focus of recent research has been on microbicide acceptability, including identification and measurement of factors that contribute to initiation and sustained use of microbicides in various populations, from Tanzanian adolescents to married women in India or female sex workers in Benin. For example, she conducted mixed-method research in parallel to a phase two microbicide safety trial to first develop scales (e.g., HIV risk perception, couple sexual communication, acceptability of product attributes) and then longitudinally assess their influence on consistent use. More recently, she applied her understanding of how social and sexual contexts shape acceptability in order to develop and test messages and materials for potential microbicide introduction initiatives in Kenya. Other research topics have included assessment of infant feeding practices, as well as adolescent abortion. Betsy brings to FHI experience in the training and use of qualitative research methods, and she is especially interested in exploring ways to make qualitative analysis more systematic and rigorous and to make qualitative and quantitative approaches more compatible. She has a PhD in health behavior from the Gillings School of Public Health, University of North Carolina at Chapel Hill, and an MA in international development from the Nitze School of International Studies, The Johns Hopkins University. Betsy has over 25 years of experience living and working in developing countries, including various countries in West and North Africa, eastern Africa, and India.

Priscilla R. Ulin is retired from Family Health International (now FHI 360), where she was senior research scientist in the Social and Behavioral Sciences division and, through her work in the early days of the AIDS epidemic, she helped establish the organization's qualitative research program. Trained in quantitative social research, she discovered the power of qualitative methods while studying maternal and child health decision making in Botswana in the early 1970s. From then on in her professional career, she combined quantitative and qualitative techniques in research, teaching, and technical assistance in sexual, reproductive, and maternal and child heath in the United States and developing countries. As a medical sociologist, she focused primarily on social change and utilization of health care systems, with an emphasis on the influence of family and community in sexual and reproductive health decision making, and on community participation in research. Dr. Ulin worked in Haiti under the auspices of FHI's USAID-funded AIDSTECH Project, where she pioneered the use of qualitative methods to explore women's sense of vulnerability in the AIDS epidemic. She was deputy director of FHI's Women's Studies Project, a five-year, multinational program of social and behavioral science research, both qualitative and quantitative, on the consequences of family planning for women's lives. She has directed research in sub-Saharan Africa on women's strategies to control their fertility, on the impact of family planning on women's participation in economic development, and on the influence of family on contraceptive decisions. Dr. Ulin received a master's degree in nursing from Yale University and a PhD in sociology from the University of Massachusetts-Amherst.

Natasha Mack is a researcher in the Social and Behavioral Health Sciences division at FHI 360. Originally trained as a linguistic and cultural anthropologist, she has 15 years of experience in qualitative research, as well as scientific writing and editing. Since joining Family Health International (now FHI 360) in 2004, she has conducted qualitative studies in HIV prevention and other public health areas, including studies on the female condom, pre-exposure prophylaxis for HIV prevention, translation issues in informed consent documents, and most recently infant and young child feeding practices. Her work has included sociobehavioral research components of clinical trials as well as standalone qualitative studies in sub-Saharan Africa and Latin America. Writing has been the mainstay of her tenure at FHI 360. This has included a field manual of qualitative methods, funding proposals, research protocols, FAQs and informational briefs, standard operating procedures, executive summaries, presentations, book chapters, and write-up of study results in final reports and peer-reviewed publications. She has also mentored staff in writing peer-reviewed articles. Dr. Mack speaks French and Spanish and has experience in French- and Spanish-to-English translation. She holds a BA (1993) in comparative area studies and Spanish from Duke University. She earned her MA (1997) and PhD (2004) in linguistic and cultural anthropology from the University of Arizona in Tucson.

Elizabeth T. Robinson is the senior advisor for communications at the University of North Carolina at Chapel Hill's $180 million MEASURE Evaluation project, funded by USAID and PEPFAR. She is a communications professional with more than 25 years of experience managing strategic communication, research dissemination, and knowledge management programs for international public health organizations. Prior to joining UNC, Ms. Robinson served as director for knowledge management for the Health Policy Project at Futures Group in Washington, DC, and she previously held several senior-level communication positions at Family Health International (now FHI 360), including director of information programs. Her work experience includes management of large editorial departments, multilingual web development, and writing on topics ranging from Ebola and health systems strengthening to HIV and gender. She has taught scientific paper writing to researchers at the National Institutes of Health, the Pasteur Institute, medical schools, and nongovernmental organizations, and she has worked as a consultant for the Johns Hopkins Bloomberg School of Public Health, the World Health Organization, the University of the Witwatersrand, and elsewhere. She is lead author of the Communications Handbook for Clinical Trials: Strategies, Tips, and Tools to Manage Controversy, Convey Your Message, and Disseminate Results; she was the principal communications advisor to the CAPRISA 004 microbicide trial; and she is the author of several qualitative studies on health communications. Ms. Robinson has devoted much of her professional life to providing technical assistance in communications to health organizations, research institutions, and sectoral ministries in Africa, Asia, and Latin America. Early in her career, she worked as a journalist in metropolitan New York; Washington, DC; North Africa; and Francophone West Africa. Ms. Robinson received a master's degree from the Columbia University Graduate School of Journalism and held a fellowship in the Columbia University School of International and Public Affairs.

Stacey M. Succop is a research associate in the Scientific Affairs department at FHI 360. Ms. Succop has been working in global health and development since 2003, and she joined FHI 360 in 2007. While at FHI 360, Ms. Succop spent more than six years working in the social and behavioral health sciences division, building her experience in study management and logistics, quantitative and qualitative data analysis, research proposal and protocol development, study team training, and scientific writing. She also facilitated relationships and communications for large, multicountry teams and was responsible for developing, coordinating, and monitoring work plans, timelines, and budgets for several simultaneous studies and projects. She worked on research studies and projects covering a wide variety of topics such as HIV prevention, mobile health interventions, family planning, and reproductive health, all in global settings. Currently, Ms. Succop serves as a scientific and technical reviewer for health, population, and nutrition-related protocols developed by staff across the organization. She provides guidance and technical support to research teams related to study design, analysis, and implementation. Ms. Succop holds a BA from Duke University; a master's degree in public health (MPH) in health behavior and health education from the University of North Carolina at Chapel Hill, Gillings School of Public Health, with a certificate in global health and a project management professional (PMP) certification.