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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 Umeå University, the Sweden-based Baltic International
School of Public Health, and the Universidad Nacional Autónoma de
Nicaragua in León, 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 León, 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
| By giving voice
to the people who actually make reproductive health decisions,
qualitative research offers opportunities to identify and
address clients' needs and concerns. |
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
— Kathleen Henry Shears
References
- Yoder PS, Camara PA, Soumaoro B. Female Genital
Cutting and Coming of Age in Guinea. Calverton, MD: Macro
International Inc., 1999.
- Waszak C. User perspectives on measures of condom
use. Study protocol. Unpublished paper. Family Health International,
2001.
- 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.
- Pimenta J, Catchpole M, Gray M, et al. Evidence
based health policy report: screening for genital chlamydial
infection. BMJ 2000;321(7282):629-31.
- 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):262-82.
- Tolley E, Kafafi L, Loza S. Impact of menstrual
changes on method use. Unpublished paper. Family Health
International, 2002.
- 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.
- Stash S. Explanations of unmet need for
contraception in Chitwan, Nepal. Stud Fam Plann
1999;30(4):267-87.
- Berglund S, Liljestrand J, de María Marín F, et
al. The background of adolescent pregnancies in Nicaragua: a
qualitative approach. Soc Sci Med 1997;44(1):1-12.
- 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.
- 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 Juárez, Mexico. Int Fam Plann Perspect
1997;23(2):52-58; Dyer SJ, 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.
- 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 Côte 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.
- Thapa S, Davey J, Waszak C, et al. Reproductive
Health Needs of Adolescents and Youth in Nepal. Kathmandu,
Nepal: Family Health International, 2001.
- Rutenberg N, Biddlecom A, Kaona F. Reproductive
decision-making in the context of HIV and AIDS: a qualitative study
in Ndola, Zambia. Int Fam Plann Perspect 2000;26(3):124-30.
- Power R. The role of qualitative research in
HIV/AIDS. AIDS 1998;12(7):687-95.
- 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.
- Quirk A, Rhodes T, Stimsno GV. "Unsafe
protected sex": qualitative insights on measures of sexual
risk. AIDS Care 1998;10(1):105-14.
- 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
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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 FHI 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 FHI’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 HIV-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 is 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. "We now
understand the need to have a longer period of assessment before
we even think of doing surveillance," she said. "We
recommend budgeting time and money for at least two to three
months of assessment before choosing surveillance groups."
— Kathleen Henry
Shears
Reference
- 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.
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Changing
Attitudes Present Opportunities
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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 organization, 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.
| Shyam Thapa/FHI |
 |
| In Nepal, as in many parts of the world,
gender inequality increases reproductive health risks
among youth. |
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
- Thapa S, Davey J, Waszak C, et al. Reproductive
Health Needs of Adolescents and Youth in Nepal.
Kathmandu, Nepal: Family Health International, 2001.
- Nepal Ministry of Health, New ERA, Opinion
Research Company (ORC) Macro. Nepal Demographic and
Health Survey 2001. Calverton, MD: ORC Macro, 2002.
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Clear
Guidelines for Qualitative Research
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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.
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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. |
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network
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