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Using Qualitative Methods In Health Disparities Research

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Can easily revise questions to clarify issues raised in earlier interviews. 16 ... Were you offended by this question? 36. Types of Cognitive Probes (cont. ... – PowerPoint PPT presentation

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Title: Using Qualitative Methods In Health Disparities Research


1
Using Qualitative Methods In Health Disparities
Research
  • Anna Nápoles, Ph.D.
  • Center for Aging in Diverse Communities
  • Division of General Internal Medicine
  • May 21, 2009

2
Objectives
  • MIXED METHODS APPLICATIONS
  • Refine frameworks, concepts
  • Develop measures
  • Develop intervention

3
What is the Role of Qualitative Research?
4
Understanding Disparities Moving Research into
the Community
  • Qualitative research
  • Identify how research methods may need to be
    tailored
  • Identify mechanisms of disparities
  • Welcomes community engagement

5
Whats in the Black Box?
OUTCOME
  • a

6
Deconstructing Markers
7
When are Qualitative Methods Used?
  • Open-ended interviews typically used in new areas
    of study
  • Useful for in-depth knowledge about issues,
    especially in less studied groups
  • Especially critical in cross-cultural studies due
    to lack of information

8
What are Qualitative Methods?
  • Data consist of words, not numbers
  • Richly descriptive, open-ended
  • Focus on inductive analytic approaches
  • Many types ethnography, participant-observation,
    direct observation, focus groups, in-depth
    interviews

9
Combining Qualitative and Quantitative Methods
  • Prior to quantitative to develop concepts,
    framework, hypotheses, and content for structured
    survey items or interventions
  • After quantitative
  • to help identify reasons for survey items not
    performing well quantitatively
  • to explore possible explanations for unexpected
    results

10
Sampling in Qualitative Research
  • Purposive, nonprobabilistic
  • Deliberately select settings, persons or events
    to best answer research questions

11
Goals of Purposeful Sampling
  • Achieve representative, typical settings,
    individuals, or activities
  • Set up contrasts to examine differences between
    settings or individuals
  • (Maxwell JA. Sage Publications, Inc., 1996)

12
1. Refining a Conceptual Framework
13
Richness of Qualitative Data
Meaning of Events
Contextual Influences on Behavior
Processes Underlying Observed Relationships
14
In-depth Individual Interviews
  • Semi-structured, open-ended
  • Capture complexity
  • Interactions of individuals with their
    environments

15
In-depth Interviews (cont.)
  • Advantages
  • useful for areas with little prior work
  • allow for detailed exploration of relationships,
    phenomenon, esp. sensitive topics
  • Can easily revise questions to clarify issues
    raised in earlier interviews

16
In-depth Interviews (cont.)
  • Disadvantages
  • fewer participants
  • less able to address generalizability
  • less theory driven, less confirmatory

17
In-Depth Interviews to Expand Framework
  • Similar employment rates among low-income
    families with and without special needs children
    (1996 US Census Bureau)
  • Conclude child care systems adequately meeting
    needs of special needs
  • Qual interviews - enormous strain on family
    relations, scarce programs, working nights, high
    turnover
  • (Sunhua L. 2002)

18
Asking the Right Questions
  • NOT
  • Are you currently working FT, working PT,
    disabled, looking for work, etc.
  • BUT
  • How has your current work situation affected your
    family?

19
Revised Framework
Original Framework
  • Child with special needs
  • Child with special needs

Financial strain Stress Family functioning Resourc
es Job instability
Employment status of parents
20
2. Developing Measures of Concepts
21
Focus Groups
  • Open-ended guided group discussion with probing
    of responses
  • Led by experienced moderator usually 1 - 2 hours
  • Purposeful sampling of 6-10 homogenous
    participants per group
  • Participants stimulate comments of others
  • Audio-record and transcribe discussion

22
Focus Groups-Logistics
  • Moderator skills listening, communication,
    negotiation, cultural similarity to participants
  • Costs of group 600 - 1000 per group
    (incentives, audio-taping, transcription,
    translation, food)
  • Convenient and hospitable community setting
  • In-person recruitment works best with
    telephone/mail reminders

23
Focus Groups
  • Advantages
  • group stimulates fruitful discussion
  • spontaneity leads to discovery of new issues and
    factors
  • Disadvantages scheduling, skilled moderator,
    group setting may be inappropriate

24
Example Measures of Cultural Sensitivity of
Clinicians
  • Conducted 19 focus groups with 163 participants
  • 61 African Americans, 45 Latinos and 55
    non-Latino Whites
  • What do or dont your doctors understand about
    your culture or health beliefs?

25
Identify Themes (Codes) How Culture Might
Affect Health Care and Outcomes
  • CAM
  • Discrimination
  • Doctor Culture
  • Ethnicity of MD
  • Family
  • Immigration
  • Language
  • Modesty
  • Nutrition
  • Patient submissiveness
  • Spirituality

26
Define Domains of Each Cultural Sensitivity
Domain CAM
  • Definition MDs knowledge and acceptance of
    non-Western, non-biomedical, holistic approaches
    to health or healing
  • When I told her I was on estrogen, it was
    refreshing to hear suggestions about alternative
    types of herbal treatments.
  • AA woman gt 50

27
Develop Items Based on Definition and Wording
Used by Participants
  • Over the past 12 months, how often did doctors
  • ..ask if you would be interested in hearing more
    about alternative types of herbal treatments?
    (CAM domain)

28
Reducing Item Pool
  • Criteria
  • maintain breadth of concept, multiple
    items/concept
  • reduce redundancy (but OK to test alternate
    versions of items)
  • eliminate items that are unclear, complex, lack
    face validity, or will not translate well

29
Cognitive Interviews to Pretest Measures
30
Cognitive Interviews
  • Derived from social and cognitive psychology to
    explore processes respondents use to answer
    survey questions
  • Diagnostic tool for pretesting survey questions

31
Purpose of Cognitive Interviews
  • To learn
  • if respondents understand words and phrases as
    intended (meaning)
  • about the process of answering the questions
  • whether items are unacceptable
  • about the usefulness of response choices

32
Writing Probe Questions
  • From reduced set of items, select potentially
    problematic items for pretesting
  • Write open-ended scripted probe questions
  • worded to reveal if suspected problem with a
    specific item is present

33
Types of Cognitive Probes
  • General
  • Tell me what you were thinking when you answered
    that question
  • How easy or difficult was it to answer that
    question? Why?
  • Explore meaning of word or phrase
  • I asked you how often doctors take a genuine
    interest in you. What does the phrase genuine
    interest mean to you?

34
Types of Cognitive Probes (cont.)
  • Retrieval
  • How did you remember that?
  • Judgment
  • Why did you pick that number for your answer?
  • Response
  • Do you think that most people answer this
    question honestly?
  • Collins D. Quality of Life Research 2003.
    12229-38.

35
Types of Cognitive Probes (cont.)
  • Redundancy
  • How is the phrase give you advice about your
    diet and exercise different from the phrase
    talk to you about your diet and exercise?
  • Acceptability
  • When I asked you how often you felt discriminated
    against by doctors because of your race or
    ethnicity, you answered (read answer given).
    Were you offended by this question?

36
Types of Cognitive Probes (cont.)
  • Cultural appropriateness
  • I asked you how often doctors asked you about
    your health beliefs? What does the term health
    beliefs mean to you?

37
Sampling for Cognitive Interviews
  • Usually do not use representative samples
  • Include respondents from major segments of
    population to be sampled for main survey
  • Approximately 5-15 interviews/group, but may
    involve several rounds

38
Recruiting for Cognitive Interviews
  • Explain how their help fits into larger study,
    process of creating questions
  • Explain their role clearly
  • help us learn how to ask better questions
  • help us make questions clearer for others
  • help us to identify problems with questions
  • Pay subjects 25 - 50, interview is demanding
  • If survey is long, pretest different sections on
    different subjects

39
Conducting Cognitive Interviews
  • Individual face-to-face, in-depth interviews
  • Standard administration of closed-ended items
  • Administer probe questions at the end (or
    concurrently)
  • Typically 1 hr interview
  • Each interview audiotaped and transcribed

40
Data Analysis of Cognitive Interviews
  • Create summary of most significant problems
  • Annotated questionnaire use electronic version
    of survey to enter comments for each item
    directly under each question
  • Aggregate item-by-item comments over multiple
    interviews

41
Content Analysis of Items and Probes
  • Using qualitative analysis software, review all
    dialogue during standard administration of
    closed-ended items and open-ended probes
  • can reveal source of problems
  • can help in deciding whether to keep, modify or
    drop items
  • Allows you to examine dialogue by item
  • within groups
  • across groups/languages

42
Example of Results Unclear Phrase
  • Original item Have you had any medical tests or
    procedures in past year?
  • 26 of respondents asked for clarification
  • Probe What did you include as medical tests or
    procedures?
  • Medical test or procedures unclear (e.g., asked
    if it included dental or cosmetic procedures)
  • Item revised to include examples
  • Have you had any medical tests or procedures,
    such as blood tests, x-rays, or cancer screening
    tests?

43
Example of Results Interpreting the Question
  • Original item How satisfied are you with the
    amount of stress or worries in your life?
  • Probe Did you answer this question in terms of
    stress, worries, or both?
  • AA and Spanish-speakers - tended to answer in
    terms of worries
  • Revised item
  • How satisfied are you with the amount of worries
    in your life?
  • Warnecke RB, et al. JNCI Monographs No. 20, 1996
    29-38.

44
Pretesting in Diverse Populations
  • Greatest problems are with question
    interpretation - simplify
  • Sometimes English concepts not meaningful in
    other languages or meaning varies across groups
  • Response sets can also be problematic

45
Advantages of Cognitive Interviews
  • Identifies where responses might be affected by
    cultural or group experiences
  • Suggests ways to revise items, responses
  • Improves validity of questions

46
Disadvantages of Cognitive Interviews
  • Flags problems, but significance of the problem
    is a subjective judgment
  • When do you need to revise or drop items?
  • Based on small number of respondents
  • Time and labor intensive

47
3. Developing Interventions to Reduce Disparities
48
How did I get here?
Source http//www.ahrq.gov/clinic/3rduspstf/behav
ior/fig2shell.htm
49
Themes for Designing Peer Support Intervention
  • Project Aims
  • Identify barriers to and benefits of
    psychosocial health services
  • Preferred mode for intervention
  • Preferred intervention content

50
Mixed Methods to Develop Interventions
51
Themes
  • Informational needs
  • Early intervention
  • Fear of impending death
  • Peer support
  • Powerlessness
  • Role of family
  • Spirituality
  • Advocacy
  • Difficulty expressing feelings, needs
  • Cultural congruence
  • Trust building

52
Implications for Peer Intervention
  • Low-literacy cancer info in Spanish
  • Early case identification
  • Emotional support
  • Dispel myths
  • Peer-delivered
  • Engage family in providing support

53
Implications for Peer Intervention (cont.)
  • Advocate for patient
  • CBT
  • Client activation
  • Cultural congruence of peer and client
  • Develop trust over time, multiple personal
    contacts

54
How do I publish qualitative findings?
55
Content Analysis of Qualitative Interviews
  • Use qualitative analysis software to review and
    code transcripts
  • Allows you to examine codes and their
    frequencies
  • within groups or individuals
  • across groups or individuals
  • sorted by research interest/questions, e.g.
    ethnic differences, specialists vs. generalists

56
Coding of Transcripts
  • Directly interpret individual remarks/instances
  • Aggregate instances into categories and
    analytically define category or class
  • Search for patterns-consistencies and
    inconsistencies
  • Can manually code in margins of transcripts

57
Manuscript Preparation
  • Describe unit of analysis
  • Describe and define codes-these can be
    categories/classes, processes, behaviors
  • Provide illustrative quotes
  • Can provide frequencies of number of units coded
    for each category

58
Manuscript Preparation
  • Report consistencies and inconsistencies
  • Organize themes or codes into higher,
    interrelated level of analysis and abstraction -
    framework

59
Manuscript Preparation
  • Describe strategies for validating conclusions
  • multiple coders, deductive and inductive
    approaches, triangulate findings across methods
    or sources, verified by participants, attention
    to negative cases

60
Limitations of Qualitative Methods
  • Small number of respondents limits
    generalizability
  • Time and labor intensive analyses

61
Advantages
  • Very rich and detailed
  • Unstructured aspects allows for on-the-spot
    probing
  • Can creatively explore potential hypotheses

62
Conclusions Usefulness of Qualitative Methods
  • VITAL to health disparities research
  • INSIGHTS into relevant frameworks, questions,
    themes, constructs, items
  • EXPANDS our conceptual models of mechanisms of
    disparities-identify unanticipated factors

63
How-To Resources
  • Ward H, Atkins J. From their lives a manual on
    how to conduct focus groups of low-income
    parents. Institute for Child and Family Policy,
    Edmund S. Muskie School of Public Health,
    University of Southern Maine, 2002
    http//muskie.usm.maine.edu/focusgroupmanual/manua
    l.htm
  • Kruegar RA, Casey MA. Focus Groups A Practical
    Guide for Applied Research, 3rd ed. Thousand
    Oaks, CA Sage Publications, Inc., 2002.

64
Grant Applications
  • Qualitative Methods in Health Research
    Opportunities and Considerations in Application
    and Review
  • OBSSR, NIH
  • http//obssr.od.nih.gov/pdf/Qualitative.pdf

65
Nature of Qualitative Data
  • Exploratory, descriptive
  • Identify unanticipated phenomena and influences
  • Generate hypotheses about processes underlying
    observed relationships
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