Applying Qualitative Methods in Intervention Research Glorian Sorensen, PhD, MPH Harvard School of Public Health Dana-Farber Cancer Institute Boston, Massachusetts, USA

Qualitative methods Overview Uses of qualitative methods Toolbox of qualitative methods Integration of qualitative and quantitative methods Focus group methods Examples from my research in the US and India

Qualitative methods Qualitative versus quantitative: When to use what? QualitativeQuantitative Subject matter is unfamiliarSubject matter clearly defined Exploratory research, when relevant concepts are unknown or their definitions unclear When measurement problems are minor and have been resolved When meaning rather than frequencies are sought When detailed numerical description of a representative sample is required When flexibility of approach is needed to allow for discovery of unexpected; in-depth investigation When repeatability of measurements is important For studying selected issues, cases or events in detail When generalizability of results and comparison across populations is needed

Qualitative methods Study design Research question and guiding theoretical framework Qualitative research study design and methods –sampling (non-random, purposive, theoretically-based) –gaining access –choosing data collection methods (interviews, documents, observation, etc) –ethical considerations –validity Analysis Reporting

Qualitative methods Qualitative methods toolbox Individual interviews (structured, semi-structured) Group interviews (focus groups and non-focus groups) Observation (participant, unstructured, structured) Document and archive reviews

Qualitative methods On combining qualitative and quantitative Explore or refine constructs for surveys Pre-test surveys Pre-test intervention materials Plan for survey administration Interpret quantitative results Understand process of change that may be measured through surveys

Qualitative methods Illustrative example combining qualitative and quantitative methods Research problem: High rates of smoking among construction laborers Research aims: –conduct formative research to assess smoking patterns and factors associated with smoking among laborers –develop and test a smoking cessation intervention, using an RCT design

Qualitative methods Laborers and smoking: How can qualitative methods enhance study? Survey constructs and administration Develop intervention strategies and messages Assess intervention components Interpret quantitative study results

Qualitative methods Focus groups: What and why? Facilitated small group discussion Experiences and perspectives Exploring specific area of interest in detail; particularly useful for sensitive topics Interaction among members is key Not for generalizing findings

Qualitative methods Focus groups vs. other methods Individual interviews + multiple perspectives + observe interactions + participants help each other clarify ideas - difficult to manage - reluctant to reveal in group setting - social norms influence responses

Qualitative methods Focus groups vs. other methods Observation + more efficient + easier access - relying on reports of behavior vs. actual observations of behavior - not a natural setting

Qualitative methods Ethical considerations Informed consent Provide project description at start of group Clarify confidentiality and anonymity (within group as well)

Qualitative methods Application of qualitative methods: Example Research questions –how do construction laborers view health risks associated with occupational exposures, poor nutrition, and tobacco use? –what kinds of health promotion strategies will effective in decreasing in tobacco use and increase in consumption of fruits and vegetables?

Qualitative methods Direct observation of worksites (for project staff to learn about range of work tasks, and understand where/when/with whom workers smoke, what they eat at break/meals, sources of food) Group and individual interviews (two waves of interviews) Formed a qualitative research working group for project

Qualitative methods Sampling Observation: convenience sample; close by; no major differences by region Group and individual interviews: stratified by region; include racial/ethnic, gender, and age mix; current and former smokers Recruitment and gaining access: through international union; training sites (bias?)

Qualitative methods Topic guide development Based on theoretical model we developed by mixing existing models (behavioral theories and work environment policy theory) Working group developed topic guide Pilot tested and refined guide Revised throughout data collection (iterative)

Qualitative methods Data collection and analysis Trained staff to conduct interviews and code data Collected data and almost immediately began analysis: –group discussions –coding (structural and thematic, multiple coders) –creation of themes document –revision of focus group guides –retrieving codes for thematic analysis

Qualitative methods Application of results to the intervention Identify themes in qualitative data Define intervention methods Incorporate into intervention messages Reflect in visuals in materials Use in staff training Apply to quality assurance

Qualitative methods Examples within the laborers’ intervention materials Value of being fit for work “Being a Laborer is a demanding job. You face hazards every day, and being healthy and fit enough to meet challenges is important… Being healthy means you’ve got the strength you need to get the job done — and take care of other responsibilities too.” [General President’s introduction to the TFR]

Qualitative methods Examples within the laborers’ intervention materials Value of family and friends “Tobacco use can be a problem for your family members and your LIUNA brothers and sisters too. That’s because secondhand smoke causes over 53,000 deaths a year among people who don’t even use tobacco — spouses, co-workers, buddies.”

Qualitative methods Examples within the laborers’ intervention materials Health concerns “…[O]ne thing you can do is make good decisions about your health. Sometimes that means talking to your steward if you’re worried about on-the-job exposures or hazards. Other times, it means taking control of your personal health, and doing what you can to make your body stronger and healthier. This is where [the program counselor] can help.”

Qualitative methods Examples within the laborers’ intervention materials

Qualitative methods Planned tobacco control research in India Analysis of Global School Personnel Survey Focus groups to elucidate observed relationships Apply to intervention development

Qualitative methods Summary: Applications of qualitative methods in intervention research Understanding the social context of the population Survey development Intervention design Staff training Understanding the process of observed changes

Qualitative methods Focus groups: Size and number Six to eight participants Over-recruit slightly and reminder about group day before Three to five groups per topic of interest Saturation: when stop hearing new info

Qualitative methods Constructing a topic guide Avoid close-ended questions: going for experience and perspectives Based on your research questions Topic areas, then questions within each topic, list probes Start with icebreakers and “easy” question

Qualitative methods Data management and analysis Transcribe recordings and check In-depth analysis Analysis across groups by theme

Qualitative methods Focus groups: Composition Purposive Sub-groups — return to your research question Homogenous vs. heterogeneous

Qualitative methods Logistics Eligibility screening Conducted in primary language of group Length: 1-2 hours, no more Location: convenient Tape record Take notes (note-taker) Incentives

Qualitative methods Focus group facilitation Two people: facilitator and note-taker Show interest and respect Introduce group members and yourself Actively listen; follow leads but stay “on topic” Encourage between-participant discussion; avoid group interview dynamic Eye contact tip