1

QUALITATIVE
RESEARCH
October 5th, 2015
Fundamentals of Scholarship
MDUP Year 1.
Jane Buxton MBBS MHSc FRCPC
Professor and MPH Practicum Director SPPH
Harm reduction lead BC Centre for Disease Control

Faculty Disclosure -Jane Buxton

Relationships with commercial interests
No grants
No honoraria
No consulting fees
Employed full-time by UBC/BC Centre for Disease control

Learning objectives
a. Discuss the principles and roles of qualitative research
b. Describe the forms of qualitative research

Outline
What is qualitative research?
Why do qualitative research?
Comparison qualitative vs. quantitative
Qualitative research methods
Key informant interviews and focus groups
How to perform the research and analysis
Examples
Walk through an example - Youth Injection Prevention

Project

How do you contact Student Affairs?

Until you move to your sites: Elise
associate.dean@ubc.ca 604.875.4111, 61979
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http://mdprogram.med.ubc.ca/student-resources/studentcounselling-and-support/?login
UBC Student Health Services
UBC Wellness Centre (SUB)
UBC Student Counselling Services
Physician Health Program of BC

What are qualitative methods?

Quantitative methods generates numbers, data that is

measured (quantity)
Qualitative methods provide descriptions, non-numeric

data (quality)

Class of 2019

Quantitative (2018)

Qualitative

288 students

Room almost full

56% female

Young men and women

Mean age = 24 years

Friendly & attentive

42% prev. attended UBC

Good looking group

Why do qualitative research?

Use in complex situations with a need to

describe and understand people - their beliefs,

behaviours, practices and interactionsi
Terminology:
to explore
gain an understanding
provide insights
inform..

Helps us to understand The why

I

Wright JG, McKeever P. Qualitative research: its role in clinical research. Ann R Coll Physicians Surg. Can 2000 33:275-80

Why do qualitative research cont..?

Supplement quantitative work (MM) week 9
Illuminate results of quantitative study
Exploratory phase of research e.g. to inform quantitative survey
Play an important role in facilitating the dissemination of

research findings

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Equality vs. Equity

Source: Many versions on web; This image was adapted by the City of Portland
Office of Equity and Human Rights from the original graphic:
http://indianfunnypicture.com/img/2013/01/Equality-Doesnt-Means-Justice-Facebook-Pics.jpg

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Challenges of Access to health care

Concept

Examples

Availability

Lack of regular care provider

Wait times

Accessibility

Geography
Rural areas less clinics e.g. methadone treatment

Accommodation

Hours of clinic operations

Are outreach and mobile clinics available?

Affordability

Prescription costs
Cost of travel
Lost work to attend

Acceptability

Culturally appropriate
Languages offered/translators
Perceived stigmatizing staff

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Photo credit: Oxfam East Africa

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Why is the well not used?

Use qualitative methods observe and interview villagers
to explore
gain an understanding
provide insights .. how to address
inform.. so can learn for the future
Women do the washing and collect water
Well is in opposite direction to the river
Well is exposed no shade
Cultural beliefs
Elder has advised not to use it
No community champion

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Comparison of research approaches

Quantitative

Qualitative

Objective

Subjectively valued

One reality

Multiple realities

Reduction, control,

Discovery, description,

prediction
Measureable
Report statistical analysis
Researcher separate
Context free

understanding
Interpretive
Report rich analysis
Researcher part of process
Context dependent

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Qualitative Research Methods

Ethnography
Narrative Analysis & Life History
Participatory Action Research
In-Depth Interviews (key informants)
Focus Groups
Or combination

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Ethnography
Ethnography is the classic method for studying a social or
cultural niche about which we know very little Daly et al., 1997
Systematic study/observation of people and cultures

in their natural setting- participant observationi

Researcher cant control what happens in the field

Provides a detailed in-depth description of everyday

life and practice; sees world from others perspective

Long term engagement in field setting - typically

months/years (time consuming/costly)

i.

Brian Hoev: http://www.brianhoey.com/General%20Site/general_defnethnography.htm

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Narrative Analysis & Life History

The study of peoples stories

that involves creating,

collecting, & analyzing written
texts, videos etc
Attention to structure of
narratives as a whole
e.g. women on prison research

team write about their

substance of choice/addiction

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Participatory Action Research (PAR);

Community Based Research
Gives voice & aims to produce knowledge from

the point of view of marginalized groups

Equal power in controlling the research
Attempts to combine research, education, and
action in a single endeavor
BUT
Data Ownership
Time Consuming
Wide range of skills required
More to come week 10 FoS

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Qualitative Research Methods

Narrative Analysis & Life History
Ethnography
Participatory Action Research
In-Depth Individual Interviews (key informants)
Focus Groups
Or combination

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In-depth key informant interviews

Key informant interviews experts
Persons using or providing the service or both
Sensitive topic - uncomfortable disclosing in a group
Choose setting for the individual
Logistics
Face to face or on phone/Skype
Obtain informed consent; Collect demographics
Token of appreciation
Travel reimbursed
Honorarium - for expertise, loss of income generating activities;
cash vs. tokens.
For professionals/students draw for iPad, coffee card
Open ended/semi-structured interview guide
Usually 30mins- 1 hour; sometimes longer

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Ex. Key informant interviews

Harm reduction: policy of supply distribution1

Heard

from clients not able to get clean needles when

needed
To determine what happens on the ground - in person
interviews with service providers across BC

Blue lights in public washrooms discourage IDU2

What is the effect of blue lights in washrooms on people

who inject drugs (PWID)

Interviews with current/former PWID re perceived harms
and benefits of blue lights

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Focus group
Enable in-depth discussion (1-1.5 hours)
Small number of people (6-10)
Comfortable/familiar setting, provide food
Collect demographics (forms/hat etc)
Reimbursement travel; honorarium cash/tokens
Empowering for marginalized groups
Interactive, but maybe influenced by an individual
Participants have shared socio-cultural

background, experience, or area of concern

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Focus group
Obtain informed consent - warn re limited confidentiality
Pseudonyms/name tags
Ground rules re confidentiality, respect, expectations
Moderator introduces topic/facilitates discussion
Facilitator maybe person with experience connects with
participants

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Advantages FGI
Explores in depth knowledge of participants more quickly

and less $ (vs. interviews)

Marginalized groups; Empoweringi (Ex. PEEP)
Flexible nature allows for discovery of potentially
invaluable information
Interactive nature provides valuable insights
Increased comfort level
Reduces misunderstanding of research question

i (Kitzinger 1995; Litosseliti 2003)

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Sampling participants
Ensure diversity; variety of perspectives
Doesnt need to be representative
Be clear on inclusion/exclusion
Enrolling
Referred by clinic staff;
Experiential person e.g. board member VANDU
Sign up list at agency
Use snowball sampling
Purposive sampling
Collect demographic information so can report on

participants
Need ethics approval

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Ex. Focus groups

Perceptions of crack use and how people
reduce harms 3

Different geographic areas, sex spec. groups

What do people with hepatitis C want in their

care provision4

FGI persons referred to Public Health HCV

clinics around the province

The Caravan priorities of PWUD

FGI 17 communities around the province

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Question(ing) guide FGI and KI

Used to direct conversation, ensure cover topics
Based on lit review, previous experience
Ensure open ended questions allow sharing
Pilot with population- language, terms esp. drugs
Order topics more sensitive last, you or

someone you know.

Be flexible and ready to redirect if off topic
Thank you for sharing, thats really interesting;Id
be interested to hear if others feel the same
Guide is not static; discuss/review after interviews
Assess question flow; overall perspective
Saturation no new information, same response
Flush out topics mentioned but not explored

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Data collection
Note taking
Flip chart (FGI)
Audio tape
+/- transcription
Video taping
Field notes
Research diary
Bracketing - admit
priori biases/

your a
perceptions

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Analysis
Synthesize and make sense of data to identify patterns,

themes etc.
Iterative process

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Analysis
Research team or individuals review notes and

transcriptions (verbatim)
Ensure personal identifiers removed
Identify areas need clarity /listen to tape
Team / 2 people read through (some/all)
Identify some broad themes
Categories / codes
Identify salient quotes which fit with themes and categories

Problems using harm reduction sites?

1. I cant get to the clinic during the times its open - its only open 8:30
to 4:30
2. The only place I can get supplies from is 20 miles from where I live
and they will only give me 25 needles at a time.
3. They take one look at me and tell me to wait outside the building
4. When I ask for needles they thrust them in my hand to get rid of me
quickly. I dont get a chance to ask the nurse about my arm infection
5. The clinic isnt open at weekends and they dont give me enough to
last till Monday so I have to reuse my needles or borrow from friends.
6. The girl on reception doesnt say hello or look me in the eye when
she speaks to me
7. I can understand they prefer to work with clean mums and babies
and dont want drug users contaminating them

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Analysis
Using hard copy transcription or notes
Make notes in margin
Identify meaning unit
Highlight text in different colours
Cut out and move on floor

software e.g. Nvivo, Atlasti organize and

manipulate data/quotes, photos, videos etc
Coding by at least 2 people, discuss and come to
consensus (reduces bias)
May use/adapt an existing framework
Use

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Use an existing framework

HCV Quality of care4 Donabedian framework

for evaluating health services:

structure / process / outcome

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Quality of HCV care from the patients

perspective4

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Quality of HCV care from the patients

perspective concept mapping4

6 of top 8 communication
Specialist/nurse is honest

with me
Specialist/nurse doesnt
talk down to me
Specialist/nurse listens to
me

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Harm reduction: policy of supply

distribution - findings1
Some sites still use needle exchange
Thought would reduce needle litter in community
Identified need for more explicit guidelines
Share evidence re why distribution with safe disposal is best
practice
Reduces HIV transmission
Reduce needle litter
Involve peers locally in needle pick up
Increase availability safe disposal boxes
Personal disposal containers

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Blue light study2

Blue lights in public washrooms to discourage IDU
SDPO project 2010/11 Crabtree A, Mercer G, Horan R,
Grant S, Tan T.
Methods:
Interviewed 18 current/former PWID
Transcribed verbatim; used Nvivo to organize data
Interpretive description- concept categories clustered into

overarching themes

Results: identified significant harms and limited benefit

i) vein damage; ii) seek next dose sooner; iii) look for other places
to inject less safe/hygienic; iv) more likely visible to police and
public

But many favoured blue lights in washroom believing their

own health and safety is less important than preventing
harms to the public internalized stigma

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Caravan identified 8 priorities

1. Improve interactions with health professionals
"The hospital won't let you in if you're a drug addict. They put you to
the back of the list... You have to be dying to get in."

2. Promote access to a range of housing options

even if you're trying to get clean. You're in a situation where all of
your neighbors are using because there's nowhere else that will rent
to you."

3. Improve treatment by police

"The police always harass you, pull up on you, ask you what you're up
to, even if you're just sitting there."

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Caravan identified priorities cont.

4. Ensure harm reduction best practices are followed
everywhere
"You give back your rigs and you get another one, but they don't give
you enough. They only give five needles and they're closed
weekends.

5. Connect with illicit drinkers

they have a safe injection site in Vancouver They should have a
building for people who drink outside, so they can be safe inside"

6. Improve social assistance

"As soon as dentists figure out you're on social assistance, they don't
want to see you.

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Caravan identified priorities cont.

7. Support user-run organizations
"It's powerful to gather. I've never heard the words 'drug war
survivors before I'm walking out of here today taller than when I
walked in.

8. Engage with and encourage allies

.. this one clinic, they'll assist you if you have an abscess. They'll
lance it right there. They won't look down on you. They're
developed from an Aboriginal point of view. At the hospital it's
terrible white people are always the first to get treated, you have
to wait for six hours because they push you right aside, and if you
need painkillers they won't give it to you because they think you're
a drug user.

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Caravan great things emerged

1. Eastside Illicit Drinkers Group for Education
(EIDGE) was formed

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Caravan great things emerged

1. Eastside Illicit Drinkers Group for Education
(EIDGE) was formed
2. Provincial harm reduction committee
Offers annual funds in each regional health authority to

support peer led initiatives

Invites peers to annual meeting
Developed how to involve people who use drugs
Research project- develop best practice guidelines for
health authorities/agencies to engage peers in
planning, policy, research and evaluation.

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Validation
Iterative process - does the next interview fit with the

themes and model

Mixed methods and Triangulation
Member checking
Taking it back same, similar, or CAB

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Youth Injection Prevention project5

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Aim
To identify what prevents street-involved youth from
transitioning into injection drug use

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Methods
Who should we interview?
How? (one-on-one interviews, focus groups)
Who should facilitate interviews?
How should we develop questions?

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Methods
Interviews with service providers
Both- FGI and interviews with youth
Trained youth to facilitate focus groups
Developed questions with youth researchers
Share your own experiences or those of someone you know

Youth Researchers practiced & tweaked the question guide

Sites identified by collaborators
Diversity e.g. LGBTQ; Aboriginal
Put up posters / sign up sheets

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Ongoing review of data/debrief

Aim: to illicit resiliency/protective factors
But heard about risks
General negative perspectives
Youth eager to leave FG

Reworded questions and prompts

What are some positive things in a youths life that help them not
to inject?
Much more positive
Almost therapeutic
Youth happy to stay longer

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Training, team building, debriefing

Coding

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Qualitative research can play an important role

in facilitating the dissemination of research
findings

HTTP://WWW.SCIVEE.TV/NODE/3624
8

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Outline
What is qualitative research?
Why do qualitative research?
Comparison qualitative vs. quantitative
Qualitative research methods
Key informant interviews and focus groups
How to perform the research and analysis
Examples
Walk through an example - Youth Injection Prevention

Project

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References
1. Buxton JA, Preston E, Mak S, Harvard S and BC Harm Reduction Supply
Services Committee. More than just needles: An Evidence-informed
Approach to Enhancing the Distribution of Provincial Harm Reduction
Supplies. Harm reduction Journal (2008), 5:37
http://www.harmreductionjournal.com/content/5/1/37
2. Crabtree A, Mercer G, Horan R, Grant S, Tan T, Buxton J. A qualitative study
of the perceived effects of blue lights in washrooms on people who use
injection drugs. Harm Reduction Journal (2013) 10:22
http://www.harmreductionjournal.com/content/pdf/1477-7517-10-22.pdf
3. Persaud S. Tzemis T, Kuo M, Bungay V, Buxton JA. Controlling Chaos: the
perceptions of crack cocaine users in Vancouver. Journal of Addiction,
(2013) Article ID 851840 http://www.hindawi.com/journals/jadd/2013/851840/
4. Brunings P, Klar SA, Butt G, Nijkamp MD, Buxton JA. It's a big part of our
lives." Defining Quality of Hepatitis C care from Patient's Perspective: A
Qualitative study." (2013). Gastroenterology Nursing 36(4)249-257
5. Tozer K, Tzemis D, Amlani A, Coser L, Taylor D, Van Borek N, Saewyc E,
Buxton JA. Reorienting risk to resilience: Street involved youth perspectives
on preventing transition to injection drug use BMC public health (2015)
http://www.biomedcentral.com/1471-2458/15/800