Answering tough questions: Why is qualitative research essential for public health

COMMENTARIES 1 Answering tough questions: Why is qualitative research essential for public health? Lindsay P. Allen Christine Kelly Andrew R. Hatala* Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada Submitted: 13 August 2023; Revision requested: 9 April 2024; Accepted: 21 April 2024 Key words: qualitative research, COVID-19, health behaviours, social epidemiology, inclusivity Introduction G lobal recognition of qualitative health research (QHR) is improving. In an 2016 Open Letter to the British Medical Journal, 76 health researchers from 11 countries called on BMJ editors and reviewers to examine their habitual rejection of QHR, pointing out that the journal’s qualitative articles are some of their most read, most downloaded, and most impactful articles.1 When calculating how often qualitative articles were published in top journals of general medicine and journals of health services and policy between 1999 and 2008, results ranged from 0% to 0.6% for the former, and 0% to 6.4% for the latter.2 While some argue reviewers are ill-equipped for assessing qualitative studies, journals have capacity to educate readers on research methods they may be less familiar with.1 In 2018, the Canadian Journal of Public Health committed to featuring QHR, consistent with having ‘maintained a long tradition of methodological diversity and a service orientation to the Canadian public health community’ (3, p611). In 2020, JAMA published key qualitative studies investigating the under-researched area of home healthcare worker burnout, giving voice to urgent recommendations for the context of widespread isolation measures in the COVID-19 pandemic.4,5 A recent Lancet-Neurology commentary showcased several valuable neurological interventions that ‘cannot be measured by numbers’, including a mental health arts festival in Scotland, a dance program for people with Parkinson’s operating in 24 countries, and one pianist/neuroscientist’s innovative research on children’s social, emotional, and cognitive development (6, p295). The complexity of global public health requires increasing sophistication and cooperation across research designs. Understanding core beliefs and values in diverse populations, incentives and demotivators, barriers and facilitators – all processes that sway public health behaviour, uptake, adherence, and thus outcomes – are in the QHR realm of expertise. Indeed, there are some public health issues that can only be understood with a qualitative approach, yet there are still issues of methodological marginalization within biomedical and public health fields. The recent COVID-19 pandemic, with accelerated public health research and dissemination to previously unparalleled rates, is an important case in point. Popular movements based on misinformation grew in part from the unfulfilled potential for more qualitative research to fill gaps in knowledge production.7 By critically examining the role of QHR in public health, and particularly arising from the COVID-19 pandemic, we present a vision for moving beyond defending QHR as valid and rigorous, to championing the use of qualitative methods as a standard of excellence in certain research areas, such as community-engaged studies on urgent emerging infectious diseases affecting socially marginalized populations. When other methods are more appropriate to a given research question, QHR is still, at the very least, an essential complement that can bolster or dialogue with even the most quantitative, clinical studies. The high standard of qualitative research in public health The success or failure of public health interventions and policies depends on how much we understand about all the factors impacting people’s decision-making; how deeply we understand social, political, economic, environmental, cultural, historical, and personal factors depends on QHR.8–10 Often critical of a reductionistic medical model of health, QHR evolves complex theories to account for the whole person within their socio-historical-cultural environments.11,12 Social epidemiologists have argued that QHR is required to investigate societal structures and stressors – and individual psychosocial processes – as determinants of health in complex causal models, and that QHR has a specific role in life-course epidemiology.11,12 Pointing out when there are more than one exposure-outcome causal pathways, qualitative studies can catch what may otherwise be missed.13 QHR excels at unsettling assumptions around terms and concepts, as well as advancing more appropriate questions, indicators, and variables.12,14 *Correspondence to: Andrew R. Hatala, Department of Community Health Sciences, Max Rady College of Medicine, University of Manitoba, 221 Human Ecology Bldg., 35 Chancellor’s Circle, Winnipeg, MB, R3T 2N2, Canada; e-mail: andrew.hatala@umanitoba.ca. © 2024 The Authors. Published by Elsevier B.V. on behalf of Public Health Association of Australia. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). Aust NZ J Public Health. 2024; Online; https://doi.org/10.1016/j.anzjph.2024.100157 2024: VOL. 48 NO. 3 Australian and New Zealand Journal of Public Health 1 2 Commentaries Qualitative research can uncover how stigma affects uptake and usage of services, and the underlying reasons for non-adherence and distrust of public health restrictions – including COVID-19 mask and vaccine hesitancy.8,15–20 This kind of knowledge is required for effective public health messaging during pandemics like COVID-19, as well as future pandemic responses and restrictions. Qualitative studies also help us understand important details about how people from specific communities interpret, react to, and cope with restrictions.21–23 For example, a qualitative COVID-19 study with the Chinese-Canadian community – among the largest Chinese diasporic populations – revealed historic-cultural factors (e.g. collectivism, mask symbolism, and previous experience with pandemics) that acted as significant drivers of adherence to physical distancing, mask use, and self-quarantine. Another article described Singaporean socio-cultural duties between older people and their adult children, calling for COVID-19 public health responses to consider the “complex web of reciprocal familial obligations” to improve adherence and efficacy (24, pe91) . QHR further helped to unpack how families experiencing divorce during COVID-19 faced compounding behaviour-impacting stressors, with implications for public health planning.25 Qualitative methods can be used not only to understand how people experience public health interventions, but also why they partook in them (or not), and how they might be improved.11 By illuminating barriers to care and to health, and conversely their facilitators, QHR provides textured knowledge on how to make healthcare work best for the people it intends to serve. In Iran, for example, QHR revealed misinformation as a main barrier to health; there was massive COVID19-related confusion due to a surge in people accessing health information from social media, as well as volumes of raw COVID-19 statistics – despite limited analytic literacy in the general population.26 Qualitative studies on healthcare provider experiences during the COVID-19 pandemic were also key in addressing specific system adaptation needs.5,27–29 QHR helps us understand how sexually transmitted and blood borne infections (STBBIs) and COVID-19 were moving through and interpreted within diverse populations.13,17,30 The call for race-based COVID-19 data was also propelled by critical social researchers that highlighted structural inequities (e.g. housing overcrowding, food insecurity) faced by Black and other racialised communities that impact virus rates and spread.31 While quantitative analysis excels at comparing COVID-19 rates between populations, QHR explores key reasons that differences exist across and within populations, and thus is crucial to implementing appropriate public health responses.13 Indeed, qualitative media analysis raised awareness of COVID-19related anti-Asian racism and its implications for stress, trauma, and mental health services for Asian populations.32 The value of social theory in public health research In their review of QHR in public health, Mykhalovskiy and colleagues specified the term ‘critical, theoretically engaged qualitative research’ to advance the full analytic potential (33, p615). With the term critical, they include scholarship which 1) commits to health equity, 2) challenges taken-for-granted assumptions in public health practice, concepts, and research, and 3) orients to epistemological tensions between social science and public health as productive – rather than antagonistic – opportunities.33 By theoretically engaged inquiry, they advise that qualitative public health research genuinely engage with foundational and evolving theories to understand social phenomena. These authors, and others before them (e.g. Willis et al., 2007), argue that the knowledge of social theory is central to high-quality QHR in public health, just as knowledge of statistics is to the conduct of robust epidemiological studies. By advancing numerous social theories over the past several decades, critical QHR has made great strides in questioning norms of objectivity, uncovering assumptions within key concepts and categories, and grasping the complexity of social phenomena.10 As Denzin similarly observed in other contexts, such strides have also been foundational to qualifying inquiry as ‘a moral as well as a scientific process’ (34, p13) via the interrogation of structural inequalities and social conditions that foster ‘inequality, poverty, human oppression, and injustice’ (p8). Social scientists draw on this long lineage of knowledge to build on and apply theories to important health issues of the day. Public health has had to rethink conventions around the categorization of groups of people, for example, as applying social theories to explanatory models of disease has helped us evolve social epidemiology.13 Indeed, one important advancement was the inclusion of stratifying data across ‘race’, naming it as an important variable while simultaneously critically observing that the socially, economically, politically, and structurally imposed origins of racial differences are not biological or evolutionary factors.13 This highlights how social theory, whether explicitly or not, informs other areas of research, as in epidemiology or clinical medicine. As Carter and colleagues (35, p110) explained, The variables in an epidemiological study are a reduction of complex values and theoretical concepts. If, in epidemiology, we classify a person according to their ‘race’ rather than their ‘ethnicity’, their ‘culture’, their ‘language spoken at home’ or the amount of ‘cultural capital’ they have access to, a theoretical choice has been made, whether or not it is acknowledged. When we treat an individual as independent in analysis, measuring nothing to do with the society, communities or cultures of which they are a part, we are making a theoretically loaded choice. (Italics added) Categories that are used in epidemiology and statistics are often constructed by people who do not live within the worldview of study participants, and this can perpetuate biases.36,37 With quantitative research we learn (and reiterate), for example, that lower-class youth have higher rates of COVID-19 than middle- and upper-class youth.11 With qualitative inquiry we learn that our analysis, interventions, and solutions must unpack the issues around class differences and inequities to be successful, rather than simply measure and label people in a way that perpetuates social stigmas, stereotypes, or problematisation in disregard of socio-historical contexts.11 In the context of COVID-19, this level of nuance is crucial to addressing public health concerns in ways that do not villainise, pathologise, and/ or polarise communities into exacerbated divisiveness and antagonistic mentalities. The push to incorporate gender diversity in health studies has largely been initiated through QHR, but it has now begun to inform quantitative methodologies such as population health surveys.38 Intersectional analysis in population health research that is grounded in theory engaged QHR is developing the landscape.21,38 Such developments include unpacking hidden assumptions embedded in COMMENTARIES statistical methodological choices, inquiring into if and how intersectional positions can be ranked, untangling intersectional identities from structural processes, and asking how different levels of oppression and privilege are measured.21,38 Public health requires a QHR-inclusive approach, and one value of social theory is that it offers critical and reflective voices to dialogue with mainstream knowledge generation and application. Black scholars, Indigenous scholars, feminist and gender scholars, disability scholars – and other scholars from and/or working with marginalised populations – tend to inform research primarily via critical qualitative methods, representing key directions for equitable access to knowledge-production and health equity more broadly.37,39–44 Participatory action, community-based, and arts-based QHR studies are necessary for ethical, democratic engagement and for the prevention of further marginalisation with youth and other nonmajority populations.45–48 Trends toward patient engagement actualized via QHR are becoming increasingly mandated by healthbased funders to improve democratic process in health research, and these processes draw heavily on QHR.49,1 These developments are mandated and supported by such organisations as the Canadian Institutes of Health Research (CIHR) Strategy for patient=oriented research (SPOR) initiative, the United States Patient=Centered Outcomes Research Institute (PCORI), and the United Kingdom’s INVOLVE Advisory Group, as well as the Declaration on Research Assessment (DORA) which has become a worldwide initiative.49,50 3 While excelling at generating knowledge about local worlds, qualitative researchers are also building international bridges. The consortia model, for example, utilises global networks of multidisciplinary research professionals to build shared vocabulary, to analyse qualitative data together, and to mobilize knowledge across contexts and settings.57 Advancing and supporting QHR in global public health will become increasingly crucial as COVID-19 and other infectious diseases continue to spread throughout the world, as previously separated communities interact with greater fluidity, and with a growing complexity of diverse and changing contexts of globalisation. Conclusion Qualitative research provides public health with valuable, complex theories, as well as profound insights into behaviour and experiences of health, disease, and healthcare. Making important contributions to tailoring public health messaging, to nuancing policy development, and to improving programs, more QHR is needed in the postpandemic recovery period and beyond. The health research community is well-equipped to tackle the work ahead: improving the visibility and literacy of QHR articles to provoke new ideas and subsequently, new possibilities in health and healthcare. To turn public health challenges into opportunities, we need more qualitative research to bolster and propel our problem-solving power. Ethics approval and consent to participate Embracing qualitative innovations and tools There is immense diversity within qualitative methodologies and methods, and this increased during the times of COVID-19. New developments, such as virtual ethnography, have become more important than ever in our digital age with its ever-changing realities of delivering health care through telehealth, learning remotely in medical education, isolating socially during the COVID-19 pandemic, and using online media for health information. Other methods like qualitative vignettes use realistic scenarios to study cultural norms, and moral and ethical frameworks in public health, nursing, medicine, social work, and education.51 This method tends to be more comfortable for participants in exploring ‘issues that might be sensitive, painful, or controversial’ such as COVID-19 vaccines, mental health problems, or HIV prenatal testing (51, p1395). Vignettes can take on audio, video, avatar, and picture formats to generate reaction, discussion, opinions, and values.51 The QHR toolbox includes different types of analyses, such as media, social media, rhetorical, archival, narrative, policy, and content analyses. Arts-based methods are flourishing because they are versatile in applicability, and highly engaging for participants, such as photovoice, photo-elicitation, digital storytelling, body mapping, mural making, reader’s theatre, theatre for living/theatre of the oppressed, and life storyboard.52–56 Qualitative researchers are continually expanding and refining methodological tools for diverse participants and study settings, which can help public health practitioners be equitably responsive to the communities they serve. 1 There is debate around using the word ‘patient’, ‘public’, ‘person’ or other alternatives in this area of knowledge because each has its own connotations. We choose to include just one term to reduce confusion. No ethics approval was required for this article. Disclosure statement No financial or non-financial interest has arisen from this research. Consent for publication Consent for publication was not required for this review article. Data availability statement There were no data sets used in this article. Funding Not applicable. Authors’ contributions LA, CK, and AH jointly conceptualized and prepared the commentary article. LA carried out a literature review on the topic and wrote first drafts of the article. CK and AH reviewed and provided feedback on the article. All authors edited and approved the final manuscript. Acknowledgements Not applicable. Conflicts of interest The authors have no competing interests to declare. 4 Commentaries Author ORCIDs Lindsay P. Allen https://orcid.org/0000-0002-7870-0301 Christine Kelly https://orcid.org/0000-0002-3316-3258 Andrew R. Hatala https://orcid.org/0000-0002-8063-5852 References 1. Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A, et al. An open letter to the BMJ editors on qualitative research. BMJ 2016; 352(February):1–4. 2. Gagliardi AR, Dobrow MJ. 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