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An overview of qualitative research methodology for public health researchers

Article · October 2014

DOI: 10.4103/2230-8598.144055

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 Revi ew A rt i c l e

An overview of qualitative research

methodology for public health researchers
A bs tra ct
Qualitative research methodology enables researchers to explore social and
behavioural issues related to public health that are not achievable with quantitative
methods. Several complex public health issues can be better understood by
exploration using qualitative methodologies. However, these methodologies are
underutilized in public health research particularly in developing countries. This paper
aims to introduce qualitative research to students and researchers in public health in
developing countries and to encourage its use in research by presenting an overview
of how to undertake a qualitative research study. Key aspects of this methodology
include choosing and working within a theoretical framework, recruitment of
participants, following the right process of data analysis, and presentation of findings
for publication.
Key words: Qualitative research methodology, public health, developing countries

INTRODUCTION
Qualitative research is useful when the research focuses on complex issues such as human behavior
and felt needs. The goal of qualitative research is therefore to help us understand social phenomena
with the help of views and experiences of all the participants.[1] While studies that ask the question
‘‘how many’’ or ‘‘how much’’ require a quantitative approach, qualitative studies usually ask the
questions, ‘‘what’’, ‘‘how’’ or ‘‘why’’ of a phenomenon.[2] Creswell defines qualitative research rather
succinctly. He states,

Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that
explore a social or human problem. The researcher builds a complex, holistic picture, analyses words, reports detailed
views of informants, and conducts the study in a natural setting.[3]
Anton N. Isaacs
School of Rural Health (MUDRIH), Qualitative research is increasingly being accepted as a necessity in public health[4] and is usually
Monash University, Australia utilized in three circumstances: 1. To study the social, cultural, economic, and political factors that
Address for the Correspondence:
influence health and disease. 2. To examine interactions between various stakeholders in an issue
Dr. Anton N. Isaacs, of public health importance and 3. To explore how people and their communities interpret health
PO Box 973, Moe, VIC, and disease.[5] For instance, a qualitative study on the beliefs of dengue prevention in a Mexican city
Australia, 3825.
E-mail: anton.isaacs@
showed that while health officials were concerned about reducing mosquito breeding sites, people
monash.edu living in areas of high mosquito density believed that they only needed to look after themselves when
they got sick so that mild fevers could be prevented from getting worse.[6] The authors of this study
Access this article online concluded that dengue prevention messages needed to be made clearer to the public in order to render
Website: www.ijmedph.org
preventive strategies more effective. Hence qualitative research methodologies enable researchers to
unpack the socio-cultural determinants of health. Within the epidemiological triad of agent, host and
DOI: 10.4103/2230-8598.144055
environment, this methodology is useful to explain disease causation by exploring how the human
Quick response code:
host interacts with the agent and the environment. It also helps identify the reasons for the different
ways of interaction. Disease prevention strategies generated out of good qualitative research tend to
be more effective since they focus on the very core of unhealthy host behavior.

Although qualitative research has been contributing significantly to public health internationally, it
is yet to receive its due in the field of public health in developing countries.[7] This paper aims to
introduce qualitative research to students and researchers in public health in developing countries

International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4 318
 Isaacs: Qualitative research in public health

and to encourage its use in research. Of course, it is impossible to right. Therefore the theory one chooses determines the issues that
condense all of qualitative research methods into one journal article. one will give priority to study, the direction that one will consider
Hence this paper only aims to provide a basic framework which to be most profitable to find answers and the kind of data that one
novice researchers could use to undertake research that requires a decides to collect.[13] It is not possible to study everything while
qualitative methodology. undertaking qualitative research. Hence, theory shapes the sort of
things that the researcher is interested in and informs the methods
Key elements of qualitative health research and techniques needed to carry out the research.[14]
As with any research endeavour, the process commences with writing
Despite the importance of following a theoretical framework in
the research proposal which is a plan or formula that researchers
qualitative research, it is not uncommon for qualitative reports
will follow in undertaking the study. Qualitative research proposals
in public health to not specify the theoretical framework that the
are different from quantitative proposals in several ways. They
study is built on. Rather they only list the number of focus groups
include the writing of the literature review, the need for a theoretical
or in-depth interviews that were conducted.[15] It is suggested that
framework, and how data will be collected and analyzed.
health researchers who do not specifically state the theoretical
The background and literature review framework that their work is underpinned by, could unwittingly be
Qualitative research articles traditionally have a detailed literature using Qualitative Description (QD) as their framework.[16,17] QD
review. The review establishes the importance of the topic and is a relatively recent method of naturalistic inquiry which aims to
provides background information needed to understand the “present a rich, straight description of an experience or an event.’’[18]
study. It also shows readers that the researchers are familiar with In QD studies, participants are asked to describe events in their own
significant and up-to-date research relevant to the topic.[8] The review words and to suggest ways of improving outcomes or changing
includes not only previous work done in the area but also types of behaviours.[19]
methodologies that have been used to undertake these studies. The
Unlike in other qualitative designs such as phenomenology,
review finally needs to state the motivation for the study and the
ethnography and grounded theory, where the researcher interprets
context from which the researcher is approaching it. This is referred
the said word within a context, in QD, the researcher stays close to
to as reflexivity and is an important component of rigor.[9]
the data. The QD design is typically valuable in answering questions
The theoretical framework such as “What reasons do people have for using or not using a service
The next step in planning a qualitative methodology is to decide on or procedure? Who uses a service and when do they use it?”.[16] The
a theoretical or conceptual framework. This can be very confusing design therefore presents rich information that may be grounded
for novice researchers because there are several theoretical in cultural and environmental contexts. This makes research using
approaches that can be used such as Phenomenology, Discourse this approach understandable not only to those experiencing
Analysis, Grounded Theory and Ethnography.[10,11] What adds to the health disparities but also to clinicians and administrators who are
confusion is that the various books and articles that describe theory responsible for reducing those disparities. Although QD lacks a
in qualitative research are all different from each other.[12] Since strong theoretical basis and is underpinned by the work of others
qualitative research has its origins in the Social Sciences, students in the field, its findings can pave the way for future theory-based
of these disciplines will be more familiar with the different theories research.[18]
that have been developed. So what is theory? In simple terms, theory
is the lens that a researcher uses to look at an issue. The Sampling strategy
Once the theoretical framework is decided, the next step is to
For example, consider the mental health problems faced by rural decide the sampling strategy. The type of sampling typically used
women. Some researchers will be more interested in identifying the in qualitative research is systematic, non-probability sampling. This
different types of clinical disorders encountered in rural women. type of sampling is not meant to select a random or representative
Others might want to study the possible risk factors as well as identify sample from a population. Rather, it identifies specific groups of
those who are the most at risk. Still others might be interested in people who either possess characteristics or live in circumstances
women’s views of, or behavior related to mental health problems. In that relate to the social phenomenon being studied.[20] Qualitative
attempting to study women’s views and behaviors some researchers sampling is therefore purposeful. Its purpose is to select information
(using the theory of ethnography) might choose to stay in the village, rich cases to study in-depth.[14]
observe their culture and traditions and how that interacts with
their illness. Whereas, phenomenologists will want to hear from the Depending on the purpose of the study, the researcher can choose
women what it means to have a mental disorder or how the illness from many strategies. In extreme or deviant sampling for instance,
has impacted upon their lives. the researcher might choose to interview patients and staff of a
popular health service as well as those from a service with poor
Both ethnographers and phenomenologists use different theories, attendance in order to highlight factors that affect service utilisation.
ask fundamentally different questions, and use different methods Maximum variation sampling is used when the purpose is to obtain
to study the same issue. Their results though not similar are both as many different views and opinions on the phenomenon being

319 International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4
 Isaacs: Qualitative research in public health

studied. For example, when studying felt needs of a rural community, a possibility that participants might feel obliged to participate in a
it might be necessary to interview individuals who are likely to have research study due to pre-existing relationships or a power imbalance,
different needs rather than choosing only housewives because they it might be necessary to invite an advocate of participants to help
are the most convenient to recruit.[21] them decide whether or not to participate in the research without
feeling any coercion.[25] Explanatory statements can be read out or
Homogenous (group) sampling is the process of choosing distributed by these advocates who can then pass on contact details
individuals who share similar characteristics of the phenomenon of those who choose to participate in the research. Alternatively,
being studied and is utilized when the aim is to study a phenomenon once individuals chose to participate in the research, these advocates
in more depth.[21] This type of sampling is appropriate for example could introduce them to the researchers.
when studying the views of final year medical students on pursuing
public health as a career. Snowball or chain sampling is utilized when Data collection
researching hard to reach populations such as drug users or homeless Interviews and focus group discussions are the most common
people. In this type of sampling, an initial respondent is asked to method of data collection in qualitative research. Interviews can
suggest other people who might be interested in participating in the be semi-structured or in-depth. In the former, the interviewer uses
research. Thus as the research progresses, the number of participants a list of broad open-ended questions to cover the core topics of
keeps increasing like a snowball grows bigger as it rolls in the snow.[21] inquiry often allowing the interviewee to digress to a certain degree
Finally there is convenient sampling where the researcher simply in order to provide a context and perhaps a possible direction that
chooses participants according to convenience. This is the easiest might be important to the phenomenon being studied. For instance,
method of sampling and is the most undesirable[22] because it can a semi-structured schedule used to study help seeking for mental
easily lead to biases and fails to theorize the sample.[14] There are health problems might start with the question, “What do people here
other types of sampling such as theoretical sampling, opportunistic do when they have mental health problems?” In-depth interviews
sampling, criterion sampling, typical case sampling and critical case on the other hand usually focus on a much smaller topic, use fewer
sampling.[14] However, these are not commonly used in public health questions and seek very detailed descriptions. A question such
research. as, “What do you feel about your illness?” might be the opening
question in an in-depth interview to study the lived experience of
The sample size a person with diabetes.
An appropriate sample size for a qualitative study is one that answers
the research question. There is no set formula or criteria to calculate All qualitative researchers need to consider how they are perceived
the sample size in qualitative research.[23] Some authors believe that by interviewees. Differences in class, race and gender can
as a rule of thumb, 12-26 people might seem right.[24] However, most significantly alter the way interviewees respond in an interview and
researchers start with a minimum sample based on the purpose of that needs to be properly addressed by the researcher.[26] The more
the study, expected coverage and interests of the researcher.[23] In comfortable a person is the more honest he or she is likely to be.
public health, it is conventional to commence the research with a Therefore, to get the best out of an interview, it is advisable to use
sample size based on the above considerations. During the course a relaxed and conversational style of interviewing and to conduct
of data collection, when little new information comes out of it in an environment where both the interviewee and interviewer
interviews or focus groups, the researcher can consider to have feel safe. Experienced interviewers will provide an atmosphere
achieved saturation of data. Occasionally, it might be necessary to that encourages the interviewee to speak freely yet steering them
expand on the original sample. However, this decision can be taken seamlessly in the desired direction to obtain maximum value for
only during the course of data collection. the time spent.

Participant recruitment The focus group discussion is not just the process of interviewing
Prior to undertaking research within communities, it is customary several people at once to save time. In a focus group, the researcher
to discuss the study with both formal and non-formal community is able to examine issues more thoroughly by encouraging discussions
leaders. This process generates trust for the researcher and support between participants. When participants share anecdotes and points
for the work. It also gives the researcher an opportunity to ensure of view and comment on each other’s experiences, it can help them
that no harm or embarrassment comes to the community as a result to explore and clarify their views in ways that would be less easily
of the research. accessible otherwise.[27] Furthermore, everyday communication that
includes jokes, teasing and arguing that can occur during a focus
The method of participant recruitment is primarily an ethical issue. group discussion can give the researcher an insight into people’s
Pre-existing relationships between participants and researchers knowledge and attitudes that reasoned responses to questions may
might compromise the voluntary nature of participants’ responses. fail to do.[27] Again, focus groups work best when all participants
Furthermore unequal relations that exist for example between are comfortable with each other. Factors that affect interviews as
lecturers and students, doctors and patients, other service discussed above are likely to affect focus groups as well particularly
providers and the people who utilize the service could influence when differences in caste, class and gender occur between members
the authenticity of the data collected. In situations where there is of the group. Conducting focus group discussions on sensitive

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 Isaacs: Qualitative research in public health

topics has challenges of its own and could produce poor outcomes analysis to be undertaken by two or more researchers so that each
unless the discussion is facilitated by a peer who has the trust and individual’s codes and their meanings can be discussed and clarified.
confidence of the group. See Table 1 for a comparison of the In addition, it will add to the rigor of the study and thereby to the
advantages and limitations of focus groups and semi-structured trustworthiness of the research. Additionally, including contrasting
interviews. views and ideas helps to provide the reader with alternate opinions.
Once all data has been coded, the researchers then group codes
Data analysis into tentative themes[29] or categories.[28] In order to do this, they
Interviews and focus groups are recorded using either an analogue look for connections between codes or if there is evidence that may
or digital voice recorder. These recordings are then transcribed. suggest that data may be associated with more than one code. When
Transcripts of interviews form the foundation on which the analysing large volumes of data, researchers frequently utilize the
process of data analysis is built. Analysis is what researchers do assistance of computer software such as Coding Analysis Toolkit
to make sense of the data (in the form of transcripts) that they (open access), Atlas.ti and NVivo (Proprietary).
have collected. There are different approaches that researchers
use in analysing qualitative data and this depends on the nature of The final step in analysis is the process of linking the different
the research question. The first step in qualitative data analysis is categories to develop a logical explanation (or a theory) for the
immersion in the data where the researcher reads and re-reads the phenomenon being studied and linking it with the existing literature.
interview transcripts and listens to the recordings in order to obtain In doing so, these categories or tentative themes might be renamed
a sense of what has been said.[28] While reading through the data, and defined to reflect key components of the phenomenon being
researchers should consciously ask themselves what stands out or studied. These renamed categories are referred to as themes and
strikes them as being part of the answer to the study question. In this analytic process is called thematic analysis.[30] Furthermore, in
order to remain focussed on the research question, the researchers demonstrating trustworthiness or rigor of the research, researchers
will need to go back and forth between the data, the study aim and employ a process called Triangulation wherein findings are
theoretical framework. substantiated by comparing data from different sources.[31]

The next step in analysis is coding. In this step, while reading through Providing feedback to the community
the data, the researcher assigns codes to chunks of data. Codes are Once a study has been completed, researchers commonly shift their
labels applied to segments of the transcript that describe them. At the focus to presenting the findings at conferences or publishing them
start of the coding process, researchers might feel like they have too in scientific journals. As a result, there is little or no feedback of
many codes. However, with more reading, two or more codes may the research findings to the community. Research can be made most
be collapsed into one. This process can be quite laborious at first but beneficial to the common person through proper feedback to the
becomes easier and more exciting over time. It is advisable for data participants and the communities that they represent. I believe that

Table 1: Advantages and limitations of focus groups and one-to-one interviews

Method of data collection Advantages limitations
Focus groups Useful when the researcher is looking for a range Difficult to conduct unless there are already
of opinions and understanding in a community in order established informal groups such as those in
to improve a health service[14] college or women’s and men’s groups
Provides insights into complex thoughts and behaviours Hard to conduct when group members are not
of people as they compare and contrast their experiences familiar with each other.
and views[41]
Group interaction could encourage participants who might Group opinions may silence an individual’s need
otherwise say little[14,27] to express dissent.[27]
Unintentional mistakes can be corrected by others Confidentiality may be compromised with the
in the group[14] presence of others in the group[27]
Can provide an in-depth understanding of how and why Emergence of group opinions rather than
people have different views, the strength of their attitudes individual opinions which may be more complex
and the factors that influence them[42] and different. More assertive personalities in the
group can push their opinions to the fore.
Sensitive to cultural issues[27] and useful when collecting Analysis is complex and involves three layers:
information from marginalized groups such as ethnic Individual, group and group interaction[43]
minorities, commercial sex workers and children.[14]
One-to-one interviews Provide more detail about an individual’s understandings Consumes a lot of time and energy
and experiences than can be gained through focus groups[1]
Good way of discovering subjective meanings and Need for several interviews to obtain useful data
interpretations of people’s experiences[44] in public health research.
Participants may be more prepared to share sensitive Difficult to do well. Depends largely on the
and personal information in private[1] sensitivity and persistence of the interviewer as
well as on the interpersonal interaction[14]

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 Isaacs: Qualitative research in public health

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Source of Support: Nil, Conflict of Interest: None declared.
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