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Using Qualitative Methods In Health Disparities Research

Anna Nápoles, Ph.D.Center for Aging in Diverse Communities

Division of General Internal MedicineMay 21, 2009

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Objectives

MIXED METHODS APPLICATIONS

Refine frameworks, concepts Develop measures Develop intervention

What is the Role of Qualitative Research?

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Understanding Disparities: Moving Research into the Community

Qualitative research: Identify how research methods may need

to be tailored Identify mechanisms of disparities Welcomes community engagement

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OUTCOME

What’s in the Black Box?

Deconstructing Markers

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When are Qualitative Methods Used?

Open-ended interviews typically used in new areas of study

Useful for in-depth knowledge about issues, especially in less studied groups

Especially critical in cross-cultural studies due to lack of information

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What are Qualitative Methods?

Data consist of words, not numbers Richly descriptive, open-ended Focus on inductive analytic approaches Many types: ethnography, participant-

observation, direct observation, focus groups, in-depth interviews

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Combining Qualitative and Quantitative Methods

Prior to quantitative: to develop concepts, framework, hypotheses, and content for structured survey items or interventions

After quantitative: – to help identify reasons for survey items not

performing well quantitatively– to explore possible explanations for

unexpected results

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Sampling in Qualitative Research

Purposive, nonprobabilistic Deliberately select settings, persons or

events to best answer research questions

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Goals of Purposeful Sampling

Achieve representative, typical settings, individuals, or activities

Set up contrasts to examine differences between settings or individuals

(Maxwell JA. Sage Publications, Inc., 1996)

1. Refining a Conceptual Framework

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Meaning of Events

Richness of Qualitative Data

Contextual Influences on

Behavior

Processes Underlying Observed

Relationships

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In-depth Individual Interviews

Semi-structured, open-ended Capture complexity Interactions of individuals with their

environments

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In-depth Interviews (cont.)

Advantages– useful for areas with little prior work

– allow for detailed exploration of relationships, phenomenon, esp. sensitive topics

– Can easily revise questions to clarify issues raised in earlier interviews

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In-depth Interviews (cont.)

Disadvantages– fewer participants

– less able to address generalizability

– less theory driven, less confirmatory

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In-Depth Interviews to Expand Framework

Similar employment rates among low-income families with and without special needs children (1996 US Census Bureau)

Conclude child care systems adequately meeting needs of special needs

Qual interviews - enormous strain on family relations, scarce programs, working nights, high turnover

(Sunhua L. 2002)

Asking the Right Questions

NOT:

Are you currently: working FT, working PT, disabled, looking for work, etc.

BUT:

How has your current work situation affected your family?

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Revised Framework

Child with special needs Child with special needs

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Employment status of parents

Financial strainStress

Family functioningResources

Job instability

Original Framework

2. Developing Measures of Concepts

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Focus Groups

Open-ended guided group discussion with probing of responses

Led by experienced moderator; usually 1 - 2 hours

Purposeful sampling of 6-10 homogenous participants per group

Participants stimulate comments of others Audio-record and transcribe discussion

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Focus Groups-Logistics

Moderator skills: listening, communication, negotiation, cultural similarity to participants

Costs of group: $600 - $1000 per group (incentives, audio-taping, transcription, translation, food)

Convenient and hospitable community setting In-person recruitment works best with

telephone/mail reminders

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Focus Groups

Advantages– group stimulates fruitful discussion

– spontaneity leads to discovery of new issues and factors

Disadvantages: scheduling, skilled moderator, group setting may be inappropriate

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Example: Measures of Cultural Sensitivity of Clinicians

Conducted 19 focus groups with 163 participants

61 African Americans, 45 Latinos and 55 non-Latino Whites

What do or don’t your doctors understand about your culture or health beliefs?

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Identify Themes (Codes): How Culture Might Affect Health Care and Outcomes

CAM Discrimination Doctor Culture Ethnicity of MD Family Immigration

Language Modesty Nutrition Patient

submissiveness Spirituality

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Define Domains of Each Cultural Sensitivity Domain: CAM

Definition: MD’s knowledge and acceptance of non-Western, non-biomedical, holistic approaches to health or healing

“When I told her I was on estrogen, it was refreshing to hear suggestions about alternative types of herbal treatments.”

AA woman > 50

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Develop Items Based on Definition and Wording Used by Participants

Over the past 12 months, how often did doctors…

..ask if you would be interested in hearing more about alternative types of herbal treatments? (CAM domain)

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Reducing Item Pool

Criteria:– maintain breadth of concept, multiple

items/concept– reduce redundancy (but OK to test alternate

versions of items)– eliminate items that are unclear, complex, lack

face validity, or will not translate well

Cognitive Interviews toPretest Measures

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Cognitive Interviews

Derived from social and cognitive psychology to explore processes respondents use to answer survey questions

Diagnostic tool for pretesting survey questions

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Purpose of Cognitive Interviews

To learn … if respondents understand words and

phrases as intended (meaning) about the process of answering the

questions whether items are unacceptable about the usefulness of response choices

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Writing Probe Questions

From reduced set of items, select potentially problematic items for pretesting

Write open-ended scripted probe questions– worded to reveal if suspected problem

with a specific item is present

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Types of Cognitive Probes

General– Tell me what you were thinking when you

answered that question– How easy or difficult was it to answer that

question? Why? Explore meaning of word or phrase

– I asked you how often doctors take a genuine interest in you. What does the phrase “genuine interest” mean to you?

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Types of Cognitive Probes (cont.)

Retrieval– How did you remember that?

Judgment– Why did you pick that number for your answer?

Response– Do you think that most people answer this

question honestly?Collins D. Quality of Life Research 2003. 12:229-38.

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Types of Cognitive Probes (cont.)

Redundancy– How is the phrase “give you advice about your diet

and exercise” different from the phrase “talk to you about your diet and exercise”?

Acceptability– When I asked you how often you felt discriminated

against by doctors because of your race or ethnicity, you answered (read answer given). Were you offended by this question?

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Types of Cognitive Probes (cont.)

Cultural appropriateness– I asked you how often doctors asked you about

your health beliefs? What does the term ‘health beliefs’ mean to you?

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Sampling for Cognitive Interviews

Usually do not use representative samples Include respondents from major segments

of population to be sampled for main survey

Approximately 5-15 interviews/group, but may involve several rounds

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Recruiting for Cognitive Interviews

Explain how their help fits into larger study, process of creating questions

Explain their role clearly: – “help us learn how to ask better questions”– “help us make questions clearer for others” – “help us to identify problems with questions”

Pay subjects $25 - $50, interview is demanding If survey is long, pretest different sections on

different subjects

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Conducting Cognitive Interviews

Individual face-to-face, in-depth interviews

Standard administration of closed-ended items

Administer probe questions at the end (or concurrently)

Typically 1 hr interview Each interview audiotaped and transcribed

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Data Analysis of Cognitive Interviews

Create summary of most significant problems:– Annotated questionnaire: use electronic

version of survey to enter comments for each item directly under each question

– Aggregate item-by-item comments over multiple interviews

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Content Analysis of Items and Probes

Using qualitative analysis software, review all dialogue during standard administration of closed-ended items and open-ended probes– can reveal source of problems– can help in deciding whether to keep, modify or

drop items Allows you to examine dialogue by item

– within groups– across groups/languages

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Example of Results: Unclear Phrase

Original item: Have you had any medical tests or procedures in past year?– 26% of respondents asked for clarification

Probe: What did you include as medical tests or procedures?

Medical test or procedures unclear (e.g., asked if it included dental or cosmetic procedures)

Item revised to include examples:– Have you had any medical tests or procedures, such as blood

tests, x-rays, or cancer screening tests?

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Example of Results: Interpreting the Question

Original item: How satisfied are you with the amount of stress or worries in your life?

Probe: Did you answer this question in terms of stress, worries, or both?

AA and Spanish-speakers - tended to answer in terms of worries

Revised item– How satisfied are you with the amount of worries in your

life?Warnecke RB, et al. JNCI Monographs No. 20, 1996; 29-38.

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Pretesting in Diverse Populations

Greatest problems are with question interpretation - simplify

Sometimes English concepts not meaningful in other languages or meaning varies across groups

Response sets can also be problematic

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Advantages of Cognitive Interviews Identifies where responses might be

affected by cultural or group experiences Suggests ways to revise items, responses Improves validity of questions

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Disadvantages of Cognitive Interviews

Flags problems, but significance of the problem is a subjective judgment– When do you need to revise or drop items?

Based on small number of respondents Time and labor intensive

3. Developing Interventions to Reduce Disparities

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How did I get here?

48Source: http://www.ahrq.gov/clinic/3rduspstf/behavior/fig2shell.htm

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Themes for Designing Peer Support Intervention

Project Aims

Identify barriers to and benefits of psychosocial health services

Preferred mode for intervention

Preferred intervention content

Mixed Methods to Develop Interventions

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Themes

Informational needs Early intervention Fear of impending death Peer support Powerlessness Role of family

Spirituality Advocacy Difficulty expressing

feelings, needs Cultural congruence Trust building

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Implications for Peer Intervention

Low-literacy cancer info in Spanish Early case identification Emotional support Dispel myths Peer-delivered Engage family in providing support

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Implications for Peer Intervention (cont.)

Advocate for patient CBT Client activation Cultural congruence of peer and client Develop trust over time, multiple personal

contacts

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Content Analysis of Qualitative Interviews

Use qualitative analysis software to review and code transcripts

Allows you to examine codes and their frequencies:– within groups or individuals– across groups or individuals– sorted by research interest/questions,

e.g. ethnic differences, specialists vs. generalists

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Coding of Transcripts

Directly interpret individual remarks/instances Aggregate instances into categories and

analytically define category or class Search for patterns-consistencies and

inconsistencies Can manually code in margins of transcripts

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Manuscript Preparation

Describe unit of analysis Describe and define codes-these can be

categories/classes, processes, behaviors Provide illustrative quotes Can provide frequencies of number of

units coded for each category

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Manuscript Preparation

Report consistencies and inconsistencies

Organize themes or codes into higher, interrelated level of analysis and abstraction - framework

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Manuscript Preparation

Describe strategies for validating conclusions:

multiple coders, deductive and inductive approaches, triangulate findings across methods or sources, verified by participants, attention to negative cases

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Limitations of Qualitative Methods

Small number of respondents limits generalizability

Time and labor intensive analyses

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Advantages

Very rich and detailed Unstructured aspects allows for on-the-

spot probing Can creatively explore potential

hypotheses

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Conclusions: Usefulness of Qualitative Methods

VITAL to health disparities research

INSIGHTS into relevant frameworks, questions, themes, constructs, items

EXPANDS our conceptual models of mechanisms of disparities-identify unanticipated factors

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“How-To” Resources

Ward H, Atkins J. From their lives: a manual on how to conduct focus groups of low-income parents. Institute for Child and Family Policy, Edmund S. Muskie School of Public Health, University of Southern Maine, 2002: http://muskie.usm.maine.edu/focusgroupmanual/manual.htm

Kruegar RA, Casey MA. Focus Groups: A Practical Guide for Applied Research, 3rd ed. Thousand Oaks, CA: Sage Publications, Inc., 2002.

Grant Applications

Qualitative Methods in Health Research: Opportunities and Considerations in Application and Review

OBSSR, NIH

http://obssr.od.nih.gov/pdf/Qualitative.pdf

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Nature of Qualitative Data

Exploratory, descriptive

Identify unanticipated phenomena and influences

Generate hypotheses about processes underlying observed relationships