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Many uses for qualitative research: findings guide study and program design, help explain quantitative data, and explore new issues.

Greater attention to reproductive health resulting from the 1994 International Conference on Population and Development, and questions about sexual behavior raised by the global HIV/AIDS epidemic, have heightened interest in the use of qualitative research. As such research expands into new areas, its many findings are being used to guide research and program design, complement findings from quantitative studies, and explore issues that are hidden or have received little study.

One way that qualitative research methods are used is in "formative" research to inform the design of a study or program. Findings from such research help survey designers in many ways: from identifying the most appropriate way to phrase a question to determining which questions to ask and whom to survey.

For example, researchers from the U.S.-based Macro International Inc. conducted qualitative research, funded by the U.S. Agency for International Development (USAID), in Guinea's four regions to determine how to formulate questions about female genital cutting for the country's 1999 Demographic Health Survey. In each region, the research was conducted in at least one rural and one urban setting, selected for ethnic homogeneity, ease of access, and political security. Female interviewers conducted individual interviews with unmarried girls, married women younger than 20, and women older than 40; they also held group discussions with women from each of these groups. Male interviewers conducted interviews and facilitated group discussions among both married men younger than 35 and men older than 40. The researchers found that it was easier for women to speak of their experiences when female genital cutting was addressed as one element of a girl's preparation for adulthood. They also learned that Guinean languages do not have words for the different types of female genital cutting, so researchers should ask instead about what occurs during the procedure. (1)

Qualitative methods are sometimes used to refine quantitative measures. A study conducted by FHI and Cameroon's Institute of Research and Behavioral Studies has attempted to identify ways to improve the accuracy of self-reported condom use by asking 40 women who had participated in an HIV-prevention clinical trial how they would decide to answer three standard questions about condom use. In-depth interviews with these women explored the most common sources of response bias in condom use studies, addressing participants' comprehension of the questions, their ability to remember the events in question, and the degree to which they thought about an interviewer's possible reaction to their responses. Findings from this research will help researchers design study questions that are worded in such a way as to minimize the potential for response bias. (2)

Qualitative findings can also offer important insights for program design. In Glasgow, Scotland, researchers from the University of Glasgow and the Sandyford Initiative (a sexual, reproductive, and women's health program) interviewed women who had recently been diagnosed with chlamydial infection to identify ways to ease the psychological and social effects of such a diagnosis. Recurrent themes emerging from these interviews were perceptions of stigma associated with sexually transmitted infection (STI), concerns about fertility, and anxiety about partners' reactions to the diagnosis. Based on these findings, the authors recommended that pilot programs in two areas of the United Kingdom provide information about screening in ways that destigmatize chlamydial infection. They emphasized that support services were needed to reassure women receiving a diagnosis of STI and to counsel them on notifying partners. (3) In the pilot programs, nurses at family planning clinics and other primary care settings received special training so they could discuss the implications of test results with clients. Clients who tested positive were referred to local genitourinary medicine clinics for treatment, counseling on notification of partners, and further testing for other infections. (4)

A year-long qualitative study with young men in low-income neighborhoods in Rio de Janeiro helped researchers from Brazil's instituto Promundo develop interventions to help such young men acquire healthy attitudes about gender roles and intimate relationships. The Instituto Promundo study involved regular observation and interaction with 25 young men identified as having more respectful attitudes toward women or being less accepting of violence against women than many of their peers. It also included formal focus group discussions and informal group discussions with young men, young women, and adults; biographical interviews with nine of the 25 young men; and interviews with family and community members Insights from this research, including the importance of male role models and reflection on the potential dangers of some traditionally masculine behaviors, were used to design programs for young men in two communities. Instituto Promundo and its partners also used lessons from these programs and the qualitative research to develop training sessions and manuals in Spanish and Portuguese for programs working with young men. (5)

Combining methods

When a study includes both quantitative and qualitative methods, researchers can use qualitative findings to better understand quantitative results and to enhance validity of the study as a whole. Qualitative methods can help researchers explain quantitative findings because they allow study participants to express why they think and act the way they do and to describe the social and economic factors that influence their decisions.

For example, a quantitative study in which FHI and the Egyptian research firm Social Planning, Analysis and Administration Consultants followed new users of intrauterine devices (IUDs), Norplant, and depot-medroxyprogesterone acetate (DMPA) in Egypt for 18 months found that method discontinuation was associated with the duration of menstrual bleeding. Meanwhile, qualitative research offered insights into why prolonged menstrual bleeding often leads to discontinuation. Women who participated in focus group discussions or in-depth interviews suggested that prolonged or heavy bleeding indicates that something is not right within a woman's body. They said such bleeding could mean that a woman's contraceptive method is not suitable for her particular body type, or it could be a sign of either physical weakness or serious illness. (6)

These findings were discussed at a policy workshop in Cairo in 2001 and generated recommendations that "address the need for more thorough counseling and for research on how to prevent side effects," says Elizabeth Tolley, an FHI senior research associate.

A qualitative study of men's violence against women in six Bangladeshi villages, directed by investigators from U.S.-based John Snow, Inc. and from Jahangirnagar University and the Development Research Centre in Dhaka, Bangladesh, enhanced researchers' understanding of the results of a survey of 1,305 women. The survey found that participants in either the Grameen Bank or the Bangladesh Rural Advancement Committee (BRAC) Rural Development Program were less likely to be beaten than women in villages that had no credit programs. Qualitative results from the four study villages with Grameen Bank or BRAC programs indicate that these programs may inhibit violence against women by providing loans that channel resources to their families and by making women's lives more visible through their participation in regular meetings. (7)

Researchers often rely on qualitative methods to determine why women who say they want to limit or postpone childbearing do not practice family planning. A study in Nepal that was funded by the New York-based Population Council sought answers to this question through a series of in-depth interviews with 47 women and their husbands in three rural villages of Chitwan district, where fertility survey data indicated that about 30 percent of currently married women ages 15 to 49 years had an unmet need for family planning Each woman was interviewed two to five times over 12 months, enabling researchers to see how attitudes toward family planning varied over time. Changing attitudes about family size often reflected the influence of a strong cultural preference for sons and the demands of family members for couples to produce sons. Many couples with one or more sons feared their sons might not survive childhood and therefore rejected both permanent and temporary contraceptive methods: sterilization because it would preclude replacing lost sons, and temporary methods because their use was believed to threaten fertility.

The interviews also revealed that women carefully weighed the benefits and risks of using various contraceptive methods. Poverty heightened the perceived risks of contraceptive use because many households could ill afford the cost of work lost as a result of contraceptive side effects or recuperation from a sterilization operation. Both men and women expressed concern about negative interactions with family planning clinic staff. They reported enlisting the help of someone with more experience with the health care system and consulting providers of their own ethnicity to improve their chances of obtaining adequate care and good advice at a clinic. (8)

Another question often raised by survey results is why adolescents do not protect themselves from unplanned pregnancy, even when they know about contraception. A multidisciplinary study of adolescent pregnancy in Nicaragua, conducted by researchers from Sweden's Umea University, the Sweden-based Baltic International School of Public Health, and the Universidad Nacional Autonoma de Nicaragua in Leon, explored this question. Results from the first phase of the study, consisting of 17 in-depth interviews with girls, women, and a few men and two focus group discussions involving 12 teenage girls in Leon, suggest that such pregnancies are not entirely unwanted. Romantic hopes and illusions seemed to be an important feature of unprotected intercourse for the girls and women, along with a religious belief that having children is the only acceptable justification for sex. None of the women or men had used contraception during their first sexual experiences, and most had continued to have unprotected sex, but not for lack of knowledge or affordable supplies. Girls said they were ashamed to ask for contraceptives because "nice girls don't enjoy sex," and therefore do not plan for it. (9)

In Bolivia, asking similar questions in two different forms--precoded survey questions and open-ended questions discussed in groups--helped clarify the extent of women's knowledge of breastfeeding as a child-spacing method. Sixty percent of the 416 women surveyed in communities outside Santa Cruz, Bolivia, in a study conducted by researchers from Nur University in Santa Cruz and the University of North Carolina at Chapel Hill, USA, had heard that breastfeeding protects against pregnancy.

Focus group discussions among 63 women from the same communities, however, revealed confusion about the cause, effect, and duration of lactational amenorrhea. Women in six of eight focus groups said that breastfeeding can prevent pregnancy, but most participants thought lactational infertility depends on a woman's physical constitution, rather than on meeting the three criteria of being less than six months postpartum, fully or almost fully breastfeeding, and amenorrheic. The combined qualitative and quantitative results from this study gave program planners interested in promoting the lactational amenorrhea method "both broad and in-depth data," the authors wrote. "The resulting synergy revealed more about the extent and nature of the problem under study than would have been possible using only one or the other method of data collection." (10)

Exploring new ground

Qualitative methods are well suited to investigating topics about which little is known because unstructured or semi-structured approaches allow researchers to explore issues participants raise during a study. By giving voice to the people who actually make reproductive health decisions, qualitative research offers opportunities to identify and address clients' needs and concerns.

Exploratory studies have offered insights on topics such as sexual decision-making in marital relationships, reasons for women's contraceptive preferences, perceptions of the causes and treatment of infertility, and reactions to changes in service delivery as a result of health sector reform. (11) Others have explored reproductive health challenges facing adolescents, including STIs, illegal abortion, sexual violence, and pregnancy and parenthood. (12)

In Nepal, qualitative research that was undertaken to help researchers design a national population-based household survey of the reproductive health needs of youth proved to be a rich source of information on a topic that had previously received no systematic study. (13) Another issue that had previously received little attention--the impact of HIV on reproductive health decisions in areas where HIV prevalence is high and most people do not know their HIV status--was recently addressed in a qualitative study funded by USAID and carried out by researchers from the Population Council, the University of Michigan, and the Tropical Diseases Research Centre in Zambia. The study was conducted among men and women in four areas of urban Ndola, Zambia, with different levels of socioeconomic development: two low-income, one medium-income, and one relatively high-income area Participation in focus group discussions and interviews was equally divided between men and women, and all participants were married This research revealed that, in the absence of signs or symptoms of illness, HIV did not seem to affect decisions about childbearing or contraceptive use. One exception was couples limiting their childbearing to accommodate the burden of caring for relatives' children orphaned by AIDS. The majority of women and men thought that a woman who knows she has HIV should not have more children, and they supported condom use to prevent transmission to a spouse. (14)

Dr Robert Power, a senior lecturer in medical sociology at University College London Medical School, writes that the "non-intrusive and subtle nature of qualitative research has been particularly appropriate in examining sensitive HIV-related issues" such as sexual behavior and partner infidelity. (15) Qualitative studies have also investigated communication between spouses about reproductive tract infections and partner referral for STI treatment. (16)

Exploratory qualitative studies can provide valuable insights for HIV prevention programs. In London, interviews with 96 drug users revealed three forms of unsafe sex involving ineffective condom use or condom failure, pointing to the need for a broader definition of sexual risk behavior. (17) Findings from another study in England, involving interviews with 56 adolescents, indicate that nonverbal communication can play an important role in ensuring condom use during first intercourse with a new partner. (18)

References

(1.) Yoder PS, Camara PA, Soumaoro B. Female Genital Cutting and Coming of Age in Guimea. Calverton, MD: Macro International Inc., 1999.

(2.) Waszak C. User perspectives on measures of condom use. Study protocol. Unpublished paper. Family Health International, 2001.

(3.) Duncan B, Hart G, Scoular A, et al. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. BMJ 2001;322(7280): 195-99.

(4.) Pimenta J, Catchpole M, Gray M, et al. Evidence based health policy report: screening for genital chlamydial infection. BMJ 2000;321(7282):629-31.

(5.) Barker G. Gender equitable boys in a gender inequitable world: reflections from qualitative research and program development with young men in Rio de Janeiro, Brazil. Sex Rel Ther 2000;15(3):26282.

(6.) Tolley E, Kafafi L, Loza S. Impact of menstrual changes on method use. Unpublished paper. Family Health International, 2002.

(7.) Schuler SR, Hashemi SM, Riley AP, et al. Credit programs, patriarchy and men's violence against women in rural Bangladesh. Soc Sci Med 1996;43(12):1729-42.

(8.) Stash S. Explanations of unmet need for contraception in Chitwan, Nepal. Stud Fam Plann 1999;30 (4):267-87.

(9.) Berglund S, Liljestrand J, de Maria Marin F, et al. The background of adolescent pregnancies in Nicaragua: a qualitative approach. Soc Sci Med 1997;44(1):1-12.

(10.) Bender D, Baker R, Dusch E, et al. Integrated use of qualitative and quantitative methods to elicit women's differential knowledge of breastfeeding and lactational amenorrhea in periurban Bolivia. J Health Popul Developing Countries 1990;1(1):68-84.

(11.) Maitra S, Schensul SL. Reflecting diversity and complexity in marital sexual relationships in a low-income community in Mumbai. Cult Health Sex 2002;4(2):133-51; Guzman Garcia A, Snow R, Aitken I. Preferences for contraceptive attributes: voices of women in Ciudad Juarez, Mexico. Int Fam Plann Perspect 1997;23(2):52-58; Dyer SI, Abrahams N, Hoffman M, et al. Infertility in South Africa: women's reproductive health knowledge and treatment-seeking behaviour for involuntary childlessness. Hum Reprod 2002;17(6):1657-62; Schuler SR, Bates LM, Islam MK. Paying for reproductive health services in Bangladesh: intersections between cost, quality and culture. Health Policy Plan 2002;17(3):273-80; Schuler SR, Bates LM, Islam MK. The persistence of a service delivery "culture": findings from a qualitative study in Bangladesh. Int Fam Plann Perspect 2001;27 (4):194-200.

(12.) Garside R, Ayres R, Owen M, et al. "They never tell you about the consequences": young people's awareness of sexually transmitted infections. Int J STD AIDS 2001;12(9):582-88; Tolley E. Context of Abortion Among Adolescents in Guinea and Cote d'Ivoire. Final Report. Research Triangle Park, NC: Family Health International, 1998; Silberschmidt M, Rasch V. Adolescent girls, illegal abortions and "sugar daddies" in Dar es Salaam: vulnerable victims and active social agents. Soc Sci Med 2001;52(12):1815-26; Worku A, Addisie M. Sexual violence among female high school students in Debark, North West Ethiopia. Afr Med J 2002;79(2):96-99; Kaufman CE, de Wet T, Stadler j. Adolescent pregnancy and parenthood in South Africa. Stud Fam Plann 2001;32(2):147-60.

(13.) Thapa S, Davey J, Waszak C, et al. Reproductive Health Needs of Adolescents and Youth in Nepal. Kathmandu, Nepal: Family Health International, 2001.

(14.) Rutenberg N, Biddlecom A, Kaona F. Reproductive decision-making in the context of HJV and AIDS: a qualitative study in Ndola, Zambia. Int Fam Plann Perspect 2000;26(3):124-30.

(15.) Power R. The role of qualitative research in HIV/AIDS. AIDS 1998;12(7):687-95.

(16.) Santhya KG, Dasvarma GL. Spousal communication on reproductive illness among rural women in southern India. Cult Health Sex 2002;4(2):223-36; Nuwaha F, Faxelid E, Neema S, et al. Psychosocial determinants for sexual partner referral in Uganda: qualitative results. Int J STD AIDS 2000;11(3):156-61.

(17.) Quirk A, Rhodes T, Stimsno GV. "Unsafe protected sex": qualitative insights on measures of sexual risk. AIDS Care 1998;10(1):105-14.

(18.) Coleman L, Ingham R. Contrasting strategies used by young people to ensure condom use: some findings from a qualitative research project. AIDS Care 1999;11(4):473-79.

Strengthening Behavioral Surveys

Almost 10 years of experience with surveys on the behaviors that put people at risk for HIV infection and other sexually transmitted infections in more than 20 countries have given FBI evaluation specialists a deeper appreciation of the value of qualitative research. Because these quantitative behavioral surveillance surveys (BSSs) track trends in behaviors that are often considered socially unacceptable or even illegal, qualitative methods are particularly useful in helping researchers understand survey populations, explains Dr. Tobi Saidel, evaluation, surveillance, and epidemiologic research officer in FBI's Asia Regional Office.

Since the BSSs began in Bangkok in 1993, FHI researchers and their colleagues in many countries have used qualitative methods to identify survey populations, map locations where BIV-risk behavior occurs, and determine what questions to include in surveys. In Bangladesh, for example, in response to a question included in their BSS questionnaire as a result of formative qualitative research, sex workers reported unexpectedly high levels of anal sex with clients. (1)

Survey designers use results from in-depth interviews and focus group discussions to write questions that survey participants will understand. In Vietnam, qualitative research results helped researchers rephrase standard BSS questions about sexual relations and condom use with someone other than a "regular" partner. A regular partner Js usually defined as a spouse or other live-in partner. But, in Vietnam, both casual sex and live-in partnerships outside of marriage are rare and the terms for casual partnerships have subtleties that may vary across populations and geographical areas. As a result, questions about regular partners were not easily understood.

Sometimes seemingly contradictory findings from a BSS require further investigation. In Nepal, only a small proportion of injecting drug users surveyed reported sharing injecting equipment, yet HIV surveillance found high rates of infection among injecting drug users. Results from a follow-up qualitative study revealed that some drug users hide their needles and syringes in public places, such as in a public toilet or under a bush. where others are likely to use them. "In terms of HIV transmission, people who use needles from a public place may, in fact, be sharing them, although they do not think of it in terms of sharing," Dr. Saidel said.

Understanding injecting drug use and other HIV risk behaviors that have received little study in developing countries is essential when designing a survey to capture the true extent of risk behavior. Dr. Saidel notes that in Asia, where HIV epidemics are still largely driven by commercial sex, injecting drug use, and in some countries sex between men, "the challenge for us is that we are dealing with populations that are somewhat hidden and not organized."

In the case of men who have sex with men, a definition of the study population as men who identify themselves as homosexual or bisexual will yield a different study population--and very different results--than one including men who have had sex with another man during the previous year.

Migrant workers are another population that has sometimes been difficult to define. The first BSS in Lao People's Democratic Republic included seasonal migrants because they accounted for most of the some 900 HIV infections that had been reported in that country, but found very little reported HIV-risk behavior among them. Qualitative assessments are under way among Lao migrants on both sides of their country's border with Thailand to gain a better understanding of patterns of migration and risk behavior.

Such experience has convinced Dr. Saidel and many of her colleagues that in-depth qualitative assessments of HIV-risk behavior and potential survey populations are needed to guide BSS design and interpretation of results. 'VVe now understand the need to have a longer period of assessment before we even think of doing surveillance," she said. 'VVe recommend budgeting time and money for at least two to three months of assessment before choosing surveillance groups."

--Kathleen Henry Shears

Reference

(1.) Pisani E, Winitthama B. What Drives HIV in Asia? A Summary of Trends in Sexual and Drug-Taking Behaviours. Bangkok, Thailand: Family Health International, 2001.

Changing Attitudes Present Opportunities

In Nepal, societal expectations regarding sexual behavior are more restrictive for girls than boys because a family's honor depends on a daughter's chaste, obedient behavior, according to young people participating in the qualitative phase of the country's first comprehensive study of youth reproductive health. (1) Families' fear of losing honor promotes early marriage for girls, often followed by early childbearing, which increases health risks for mothers and infants. Boys, on the other hand, cannot marry until they have achieved financial independence. They are encouraged to be sexually active before marriage, which may put them at risk of sexually transmitted infection.

Such gender inequality is a serious threat to the sexual and reproductive health of adolescents and young adults in Nepal, qualitative research findings from that comprehensive Nepal Adolescents and Young Adults (NAYA) study show.

During focus group discussions, young people ages 14 to 22 years also revealed changing attitudes toward love, marriage, and childbearing that present opportunities for improving reproductive health but could cause generational conflict.

The B.P. Memorial Health Foundation, a Nepalese nongovernmental organisation, and FHI recently conducted this qualitative research in 11 of the country's 75 districts. The districts were selected to represent urban and rural settings in Nepal's two geographic areas and five regions, as well as diverse ethnic groups and varied levels of development. In each district, local social workers helped identify young people to participate in discussions with others of the same sex and marital status. In rural districts, where educational attainment was generally low, the groups were also divided by literacy or level of education to ensure representation of youth who had gone beyond primary school as well as those with primary-level education or no formal schooling.

Qualitative research findings also suggest that poverty exacerbates the harmful effects of gender inequality, particularly for girls. Focus group participants reported that many young women in poor households do not receive the nutritious foods they need during pregnancy. Girls are often considered a financial burden, and educating them is seen as a waste of scarce resources.

Nevertheless, both the proportion of girls attending schools and the average age of marriage for young women are beginning to rise in Nepal. (2) Study participants noted these changes and reported having different views from their parents on love, marriage, and childbearing. These adolescents expect to play a larger role in choosing their spouses and to bear fewer children than their parents did. But boys and girls said they wished they could talk to their parents or other adults about personal matters such as love, romance, and sex. Young people, including married youth, had few sources of accurate reproductive health information.

Based on these qualitative findings, the study's authors made several recommendations for improving young people's access to reproductive health information and services in Nepal. They include providing comprehensive family life education for girls and boys in schools and communities, training health care providers to offer high-quality, nonjudgmental care to youth regardless of marital status, and educating parents to help them communicate with their children about sexual and reproductive health.

Other recommendations seek to address the gender inequality that increases reproductive health risk among Nepalese youth. They include creating reproductive health programs for both boys and girls and providing financial incentives for families to keep girls in school. These and other recommendations drawn from both the qualitative findings and the NAYA survey of almost 8,000 youth conducted in 2000 are being used by the government and by nongovernmental organizations, including Save the Children USA, to develop programs for youth in Nepal. NAYA findings helped the National Planning Commission develop specific plans to address youth needs in the country's tenth five-year national development plan.

--Kathleen Henry Shears

References

(1.) Thapa S, Davey J, Waszak C, et al. Reproductive Health Needs of Adolescents and Youth in Nepal. Kathmandu, Nepal: Family Health International, 2001.

(2.) Nepal Ministry of Health, New ERA, Opinion Research Company (ORC) Macro. Nepal Demographic and Health Survey 2001. Calverton, MD: ORC Macro, 2002.

Clear Guidelines for Qualitative Research

The field of qualitative research has thus far lacked a clear and systematic set of guidelines for the planning and conduct of qualitative research in sexual and reproductive health and behavior; the contexts in which reproductive health behaviors occur; and the use of research findings for program development. With the recent publication of Qualitative Methods: A Field Guide for Applied Research in Sexual and Reproductive Health, FHI hopes to help fill that gap.

The 280-page guide presents practical strategies and methods for using qualitative research, along with the basic logic and rationale for qualitative research decisions. It also raises awareness of the complexities, advantages, and limitations of qualitative methods. The guide covers a wide range of topics and leads readers through every phase of research--from theory to study design, data collection, analysis, interpretation, and dissemination. It is intended for those with formal training in the social sciences or those with research experience who want to expand their repertoire to include qualitative methods. FHI hopes this guide will contribute to the generation of new and sound information about reproductive choice, sexual risk and protection, gender relations, and other critical areas related to population, health, and disease.
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Author:Shears, Kathleen Henry
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Date:Dec 22, 2002
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