Pamina M. Gorbach, MHS, DrPHUniversity of California, Los Angeles (UCLA)

Using Qualitative Methods in STD/HIV Behavioral Research

What is qualitative research?What is qualitative research?

"Qualitative" research is the study of the wordsand the meaning behind behaviors.

Seeks to answer "WHY" people practice certain behaviors

Collects words for data.

What is quantitative research?What is quantitative research?

”Quantitative" research is the study of numbers. Asks "how many" people practice "how many" differentbehaviors. Main tool is the survey.

The aim is to find numerical patterns in responsesto survey questionnaires or observed behaviors. Indicates magnitude of people's decisions andbehaviors.

Uses of Qualitative methods

QUALITATIVE QUANTITATIVE RESULTS

Model 1

Steckler et al. 1992

1. A tool to generate ideas.2. A preliminary step in developing a quantitative study.

Uses of Qualitative methods

QUALITATIVE

QUANTITATIVE RESULTS

Model 2

Steckler et al. 1992

3. To help understand the results of a quantitative study.

Uses of Qualitative methods

QUALITATIVE QUANTITATIVERESULTS

Model 3

Steckler et al. 1992

4. The primary data collection method – sometimes but not necessarily along with a quantitative study like a survey

Main Data Collection Main Data Collection MethodsMethods

In-depth individual interviewsIn-depth individual interviews

Focus groupsFocus groups

Participant observationParticipant observation

Pile sortingPile sorting

Individual InterviewsIndividual Interviews

AKA Ethnographic interview = open-ended, in-depthinterview with one individual.

Probes; collects respondent’s perspectiveand words; follows guide; level of structure varies.

WHEN???•Complex subject matter and knowledgeable respondents

•Highly sensitive subject matter

•Geographically dispersed respondents

•Peer pressure an issue - social desirability a threat

Individual InterviewsIndividual Interviews

ADVANTAGES:ADVANTAGES: Most in-depth. Why Most in-depth. Why

behaviors are practiced.behaviors are practiced. Data on how people think Data on how people think

and talk; and talk; conceptualizations of conceptualizations of behavior. behavior.

Exact words people & Exact words people & language use amongst language use amongst themselves.themselves.

““Emic” perspective = Emic” perspective = insider’s perspective.insider’s perspective.

DISADVANTAGES:DISADVANTAGES: Based on a few people, Based on a few people,

usually not usually not systematic systematic sample, but sample, but purposeful purposeful or or convenienceconvenience sample. sample.

Not Not generalizablegeneralizable. . Interviews very long, lots Interviews very long, lots

of data! Time consuming of data! Time consuming to analyze.to analyze.

Researchers opinions of Researchers opinions of what the data means.what the data means.

Focus GroupsFocus GroupsOpen-ended group interviews that promotediscussions between participants on specific topics. Usually 6-8 individuals matched by age, gender or ethnicity.

WHEN?•Group interaction important

•Cost and timing issues

•Idea generation

•Problem identification and definition goal

•Evaluating messages for an intervention

Focus GroupsFocus Groups

ADVANTAGES:ADVANTAGES: Some people more Some people more

comfortable and talk comfortable and talk more openly in group more openly in group settings. Natural way settings. Natural way some people talk some people talk about problems and about problems and personal issues in personal issues in some cultures.some cultures.

Collects information Collects information on social norms.on social norms.

DISADVANTAGESDISADVANTAGES Difficult to access practice Difficult to access practice

of very personal or sensitive of very personal or sensitive behaviors in groups - may behaviors in groups - may only learn about behavior only learn about behavior people will admit in front of people will admit in front of others. others.

Not GENERALIZABLE Not GENERALIZABLE Transcribing time Transcribing time

consuming - often 30-40 consuming - often 30-40 pages each! Difficult to pages each! Difficult to identify speakers. analytic identify speakers. analytic challenge!challenge!

Participant ObservationParticipant Observation

The researcher becomes participant in social eventor group under study and records observations. Tellor not tell group being studied that it’s a study??

Advantages: Data is very deep and detailed.

Disadvantages: Difficult to systematically collect; especially in middle of important moment - hard to take notes so details may be forgotten. Analytic methods for observation notes not well described.

Guidelines for Qualitative Data Guidelines for Qualitative Data CollectionCollection

Don’t let interviewer/ facilitator dominateDon’t let interviewer/ facilitator dominate

Control interviews/ FGDControl interviews/ FGD

Avoid questions TOO open – burden on Avoid questions TOO open – burden on respondentrespondent

LISTEN!!!LISTEN!!! Ask followup questions Ask followup questions

Record so have direct quotationsRecord so have direct quotations

Use probes – start with neutral ones like Use probes – start with neutral ones like pauses & repetitionpauses & repetition

Common Pitfalls in Data Common Pitfalls in Data CollectionCollection

Equipment failure – tape recorder batteries Equipment failure – tape recorder batteries die, machine breaks, tapes break, or ???die, machine breaks, tapes break, or ???

Environmental Hazards – background noiseEnvironmental Hazards – background noise

Easton KL, McComish JF, Greenberg R. Avoiding Common Pitfalls in Qualitative Data Collection and Transcription. QUALITATIVE HEALTH RESEARCH, Vol. 10 No. 5, September 2000 703-707.

Transcription ErrorsTranscription ErrorsMisinterpreted Words:

Misheard Words:

Jargon or Language Barrier Problems: Easton KL, McComish JF, Greenberg R. Avoiding Common Pitfalls in Qualitative Data Collection and Transcription. QUALITATIVE HEALTH RESEARCH, Vol. 10 No. 5, September 2000 703-707.

ANALYTIC APPROACHANALYTIC APPROACH

CASE: focuses on each person or each unit. When variation in individuals primary focus of the study. Use all the data from each person.

Cross-Case: Groups together answers from different people to common questions; analyze different perspectives on central issues.

BOTH: Start with case descriptions then describe variations in answers to common questions.

How will Theory be Used?How will Theory be Used?

Apply existing?Apply existing?

Develop grounded?Develop grounded?

Content or Theme Content or Theme AnalysisAnalysis

WHAT: The identification of common themes and exploration of differences in how these themes are expressed and applied in a particular cultural context.

HOW: Careful review of written transcripts noting specific words used by respondents to understand their systems of meaning.

Spradley; 1979

CODE: an abbreviation or symbol used to classify words in the text by categories.

CODING: process to identify categories of meaning.

CODING TEXT

Miles and Huberman; 1984

DESCRIPTIVE: Summarizes, describes, or defines.e.g.,

CONCEPTUAL: Addresses the deeper meeting or conceptbehind somethinge.g.,

TYPES OF CODES

Coded Text

Coding Strategies

Individual – review and code aloneIndividual – review and code alone Consensual – review and code Consensual – review and code

transcripts “together” and come to a transcripts “together” and come to a consensus regarding codes in consensus regarding codes in disputedispute

Separate – two or more researchers Separate – two or more researchers code text separately then compare code text separately then compare

Making a Matrix or Making a Matrix or DisplayDisplay

•Once the data are coded, develop a matrixthat displays identified categories by groups of respondents.

•Enter short quotes or summarizing remarks from coded text into appropriate boxes in the matrix by category following a precise set of decision rules and criteria.

Making a DisplayMaking a DisplayTable 7: Perceived Causes of RTI Symptoms

Menstrual

Irregularity Vaginal Itching Pain with Uriination Genital Sores Abdominal Pain Abnormal Discharge Bledding Problem

Rural DK (4) Weakness (7) Hard Work Old age Menopause Bad blood (2)

DK (4) Infection (2) Insects Poor hygiene (9) Hard work Too much sun Sex (3)

Hot inside (10) DK (2) Weak Kidney (3) Hard work () Gonorrhea Kidney Stone

Poor hygiene (8) DK (5) Men not clean IUD (2) Many MRs or abortions (2) Not cleaning after sex

DK Harmful wind (3) Worms (4) Disease (2) Bad food (4) Appendix (3) Hot inside

DK (4) Irreg. Period (2) Inflammation (2) Disease (2) Many births (2) Old age Infection (3) Many MRs/abortions() Poor hygiene Hard Work Bad blood

DK (3) Too much blood (2) Old age (menopause) Weakness (2) Buffalo blood Hard work (2) Headache Leftover blood Many MRs abortions Bad blood

Urban DK (3) Weakness Menopause Period not finished Pregnancy Abnormal hormones Taking antibiotic Heavy work (2) Late abortion IUD (2) Food Stress (2) Sex Injectable fp

DK (3) Infection (3) Menstrual cloth (2) Husband caught disease Poor hygiene (6) Fungus (2) Soap IUD Gonorrhea Riding bike

Hot inside (7) Infection (7) Pregnancy Hot weather Sex w/ husband Disease (2) DK Gonorrhea or syphilis Kidney stone Husband not clean Being tired

Poor hygiene (11) Many MRs/abs (2) Menstrual cloth Disease (2) DK (2) Sex w/ husband (4) Unfaithful husband Unclean sex IUD

DK Food (10) Hot inside Infection (2) Worms (6) Weather change Kidney stone

DK (2) Infection (4) Not healthy Before period Husband got disease Poor hygiene (2) Weak/tired (6) IUD (2) Sex Abortion

DK (3) Infection (2) IUD (4) Blood not finished Weak Heavy work Sex during period Sour fruit/food Hormones Sex Injectable fp

Gorbach, PM et al 1997

More DisplaysMore Displays

Interviewee #

Present IUD Use

Past IUD Use

Persistent Symptoms

Problem

R-1 X Backache, tired, pain w/ intercourse, dizziness, less menstrual bleeding

R-2 X Pain everywhere, backache, very weak, excessively long menses

R-4 X Excessive and stinking discharge Pregnancy during use

R-7 X Pain, coughing and backache

R-8 X Bleeding for 22 days after insertion

R-11 X Itchiness, excessive menstruation Expulsion, one year after insertion

R-12 X Abdominal pain, backache

R-13 X Fever Malaria

R-14 X Dizziness, headache, weak and thin, spotting, backache, irregular menses

R-16 X Heavy menses

Gorbach, PM et al 1997

Men Women STD High

Risk Low Risk

STD High Risk

Low Risk

Monogamous marriage

X X X X X X

One-night stand X X X X X X Cohabitate X X X X X X “Fuckbuddy” X X X Sex for drugs/ $ X X X X Concurrent Now

X X X X

Partnership Type by Group

And More Displays!And More Displays!

ThemesThemes

Underlying constructs that emerge Underlying constructs that emerge from the codes and patterns from the codes and patterns observed in the data and/or were observed in the data and/or were predetermined by the researcher predetermined by the researcher and are later verified by the dataand are later verified by the data

Themes From Display: Themes From Display: “Emerge“Emerge””

(1) Look for patterns

(2) Build a logical chain of evidence

(3) Make contrasts and comparisons

(4) Cluster

(5) Count - carefully

VERIFYING THEMESVERIFYING THEMES

(1) Follow up on surprises

(2) Triangulate - > other interviews, surveys

(3) Make some if-then tests

(4) Check out rival explanations

(5) FEEDBACK - from informants, experts, colleagues, friends!

Presenting ThemesPresenting Themes

Table 3: Partners Least NotifiedTable 3: Partners Least NotifiedMen who havesex with men

Men-Heterosexual

Women

•Anonymouscontacts(e.g. bath house)

•Only oralcontacts

•Perceivedtransmitters

•Currently incarcerated

•Former partner, partnership now severed

•Those feared

•One-time partners

•Perceived transmitters

•Sexual contact before symptoms

•Sexual contact before sex with partner perceived as transmitter

A Continuum of DisclosureA Continuum of DisclosureFactors that influence HIV disclosure for Factors that influence HIV disclosure for

MSM who disclose at different ratesMSM who disclose at different ratesDisclosure much less

likely

Disclosure much more

likelySometimes Disclosure

Nobody’s Business

Denial

Undetectable VL

Just Sex

Shared Responsibility

Rejection

Drugs

Public Place

More than “Just Sex”

I am responsible

Private Place

Knew his Status

He asked me

Jail

Reasons to Not Notify:Hetero Men and Women

Reasons to Not Notify:Hetero Men and Women

Fear of gossip

“I’m not going to tell noone because then it would be embarrassing on me - they would tell everybody else and I don’t want to be know as having no STDs.” 19 year old African American Male - GC

“No, I figured they would go tell. That would be the talk of Seattle for me.” 15 year old African American Woman - CT

Using Quotes: In TextUsing Quotes: In Text

Feelings Regarding Sex: Women Who Feelings Regarding Sex: Women Who Test Positve for HPVTest Positve for HPVDoesn’t want to have sexDoesn’t want to have sex

““Oh yeah, it did. Right now, like I said, I don't want to really meet Oh yeah, it did. Right now, like I said, I don't want to really meet no guys, I mean, I could meet them, talk to them, but as further no guys, I mean, I could meet them, talk to them, but as further as having sex, no.” as having sex, no.” L2: 21/L/new/STDL2: 21/L/new/STD

Scared/concerned to infect partnersScared/concerned to infect partners““Yeah I felt depressed, I'm like damn, can't have sexual, I'm scared Yeah I felt depressed, I'm like damn, can't have sexual, I'm scared

to have sex with somebody, cause I'm scared I might give it to to have sex with somebody, cause I'm scared I might give it to him…” him…” A9: 21/AA/middle/STDA9: 21/AA/middle/STD

Feel more vulnerable can acquire something elseFeel more vulnerable can acquire something else““I'm really not messing around, you know, that much no more, I I'm really not messing around, you know, that much no more, I

don't, cause I don't, I just don't like the fact that, you know, like, don't, cause I don't, I just don't like the fact that, you know, like, somebody coulda, gave me something, or something like that, somebody coulda, gave me something, or something like that, you know, and the act like, cool, they act like they don't have you know, and the act like, cool, they act like they don't have nothing, probably because they didn't' go and check” nothing, probably because they didn't' go and check” A5: 22/A/middle/STDA5: 22/A/middle/STD

Shared Shared ResponsibilityResponsibility

Sometimes Disclosure

“It’s a 50-50 street…they should ask as well as I should tell.” (30/W/SEA)

“We have responsibility in the sense that, yes, we should tell them…but they have the responsibility to ask. It’s a 50-50 thing. It just depends on who initiates it.”

(35/AA/LA)

“I am usually expecting someone else to say something, and if they don’t, I assume that they are positive or that it does not make any difference to him.” (52/W/SEA)

Text in ManuscriptsText in Manuscripts

From: Gorbach PM, Galea J, Amani B, Shin A, Celum C, Kerndt P, Golden M. Don’t ask, Don’t Tell: Patterns of HIV Disclosure Among HIV Positive Men Who Have Sex with Men (MSM) with Recent STI Practicing High Risk Behavior In Los Angeles and Seattle. Sexually Transmitted Infections, 2004 December, 80(6):512-517.

Quotes in Manuscripts: Quotes in Manuscripts: TablesTables

Factors: INDIVIDUAL

Qualitative Data Age, Sex, Ethnicity, Site*

Fear of results “You don’t want to know. You don’t want to die.” 40s, F, W, IDU Avoidance of change

The only reason why it’s taken me a while to lead up to my first time, to get tested, … it would require a big change in my life. I guess we’re all kind of afraid of change.”

30s, M, AA, MSM

Apathy “I’m pretty much to the curb. My life has gone downhill. I’m a drug addict, I’m on the street. I’m out there running on the street. … I’m just not caring. It doesn’t matter to me much about HIV.”

40s, M, W, IDU

Chaotic Lifestyle "They got other things on their mind to worry about than having to take the time to call for an HIV test – you know what I’m sayin’? they're dopesick, and they spend most of their time hustlin’ their money to get well, so they got a lot on their mind."

40s, F,W, IDU

Denial “It took a friend of mine who died to bring me to my senses. After he died, I said I’m gonna go and try and be tested.”

50s, M, AA, IDU

Not Ready “The first time I took the test, it took me a while to go and do that because I knew that I had been doing things that I could’ve come up positive. And I wasn’t ready to deal with that. So I postponed it as long as I could, and then I lost a friend of mine, a very close of friend of mine. That made me go ahead and be tested. I don’t really know what she died from, but I know the way she died she possibly could have had AIDS. I know that me and her had done things together, shared needles, everything else. So I was afraid to get tested, what I would find out.”

30s, F, W, IDU

Self-Disclosure “I didn’t tell [the counselor] about that partner because he was using and I was embarrassed to admit I’d been with him. Besides, we weren’t together anymore.”

30s, F, W, STD

Distrust of Treatment

“I think you’re killing people with that crap. That’s just my opinion. I think they’re overloading people will all kind of pills. I think it’s possible that some of these things are making people die earlier. I’ve seen these guys with all these pills that they have to take. They’re skinny and they’re always sick. Maybe if they’d stop taking those pills, they’d start feeling better. I just have a gut feeling about that.”

40s, M, W, IDU

Ostracism “AIDS, that’s a touchy subject. ‘Cause a lot of people, they don’t even wanna walk down on the same side – some people that don’t know a lot about it they don’t even want to be around you, or touch you or nothin’.”

30’s, M, AA, IDU

Stigma of Testing “Stereotypes, labels, perceptions…It would be easier [to test] if there weren’t such a negative image associated with it.”

20s, M, AA, MSM

Risk Perception “Putting it off? I hate it. I still put it off. … I feel healthy. I do my work. I don’t think I’m at much of a risk. I’m in a monogamous relations two years.”

30s, M, W, IDU

Data Analysis: Review of Data Analysis: Review of StepsSteps

1. Collect data (conduct interviews/focus groups)

2. Manage data - transcribe interviews

3. Choose theoretical approach: grounded or applied

4. Determine analytic approach - case or cross-case

5. Code transcripts

6. Create matrices, displays - data reduction

7. Conduct theme analysis - identify themes

8. Draw conclusions - present themes

Improving Improving QualitativeQualitative Data Data QualityQuality

Data collection - consider strengths & weakness Data collection - consider strengths & weakness of indepth interviews vs focus groups of indepth interviews vs focus groups (convenience, social desirability, efficiency)(convenience, social desirability, efficiency)

Sampling – can move beyond convenience or Sampling – can move beyond convenience or “purposive” toward more representative“purposive” toward more representative

Analytic approach – use software for data Analytic approach – use software for data management & text analysis, develop matrices management & text analysis, develop matrices during analysis, identify theme through content during analysis, identify theme through content analysis, compare themes by sub-groupsanalysis, compare themes by sub-groups

Components of Data AnalysisComponents of Data Analysis

Datacollection

Data reduction

Datadisplay

Conclusions:drawing/verifying

Interactive Model of Analysis: Miles and Huberman