Review & Opinions

Qualitative Methods In Sexual Health Research

Wah-Yun Low, Ph.D
Professor of Psychology
Health Research Development Unit
Faculty of Medicine, University of Malaya
Kuala Lumpur, Malaysia

Introduction

Over the past decades, results from quantitative research on sexual issues highlighted the need for understanding of factors affecting one's sexuality, as well as a need for utilizing a different research strategy. Investigation into most aspects of sexual health issues frequently calls for qualitative design. In this regard, qualitative research plays an important role in contributing towards the exploration of this complex and sensitive issue.

Qualitative research is essentially exploratory, setting out to describe, understand and explain a particular phenomenon; and its emphasis is on meanings, experiences and view of the participants. The aim of qualitative research is understanding social behavior and thought through people's own accounts and observations of their interactions with others. Qualitative design leads us to understand behaviors, beliefs, motives, attitudes and perception that determine sexual health issues. Holloway (2005) noted that as qualitative research is person-centered, researchers consider the patients-participants in the research as whole human beings, not as a collection of physical parts/organs. This design is appropriate in sexual health research as it focuses on the person rather than a person's scores obtained on a questionnaire/scale; on the person as a member of a family or a community rather than a subject in a population/sample; focuses on the person who is ill, rather than on the illness.

Applications of Qualitative Design in Sexual Health Research

Qualitative methods can be used to explore new issues. It is well suited to investigate topics about which little is known because unstructured or semi-structured approaches allow researchers to explore issue participants raised during a study. Several studies were conducted to explore issues like reasons for women's contraceptive preferences (Guzman & Aiken, 1997), perception of causes and treatment of infertility (Dyers et. al, 2002), reactions of changes in service delivery as a result of health sector reform (Schuler, Bates, Islam, 2001), perception of erectile dysfunction and its treatment among men (Low et. al. 2006); the role of doctors in the management of erectile dysfunction (Ng, Low & Tan 2004), and it offered insights or topics in sexual decision-making in marital relationships (Maitra & Schensul, 2002). By giving voices to the people who actually make sexual and reproductive health decisions, for example, how people negotiate the use of condom during sex with an infected HIV partner, qualitative research offers opportunities to identify and address participant's needs and concerns.

Qualitative methods are often used to refine quantitative instruments, for example, structuring of questions and how and what questions to be asked in a survey, so as to minimize potential response bias. Further, qualitative research helps to explain quantitative data obtained in a survey. Sometimes findings from a qualitative research can be used to help develop a research design for a survey or it can also offer insights for program design. Qualitative research also helps shed lights on the success or failures of intervention programs, and also facilitate understanding of health policy.

Combining both quantitative and qualitative methods have also been useful for sexual health studies. Researchers use qualitative findings to better understand quantitative results and to enhance validity of the study as a whole. Qualitative study help researchers explain quantitative findings because they allow study participants to express way they think and act the way they do and to describe the social and economic factors that influence their decisions. A randomized trial of treatments for localized prostate cancer, for instance, was effectively embedded within a qualitative investigation of the feasibility of undertaking such a study (Donovan et al. 2002).

Qualitative Data Collection Methods

The common qualitative methods are mainly participant observation, in-depth interview, and focus groups.

Observational studies are fundamental to most qualitative research. A classic example of observation is a medical anthropologist conducting fieldwork in a particular community in order to observe the local culture, habits, myths and rituals related to health by living in the village or community for a prolonged period of time. Through observation, a researcher learns about behaviors and the meanings attached to those behaviors. This technique can be applied to the clinical setting, where one can observe patient's behavior in the hospital ward or in the clinic's waiting room. An observer can either be an outsider, for example, observing the interaction between doctor and patient in the ward; or an observer can also be a participant (participant observation), where he/she actively participates in an activity or event in the social setting. This form of observation can be unobtrusive and unstructured. A systematic description of events and behaviors are then noted.

Qualitative interviews are normally semi-structured questions, which probe for more in-depth information. Interviews can also be unstructured (open-ended) where the interviewer has a list of prompts or topics to focus the interview, but it is guided by the priorities of the respondent. Themes are explored using open-ended questions to elicit a response from the participants in their own words (Patton 1990). Unstructured interviews aimed to elicit a free, natural and uninhibited response, and such interviews are usually non-directive and are conducted as informally as possible.

Focus group discussions or group in-depth interviews are among the most widely used research tools to examine people's experiences of disease and of health services. Focus groups capitalize on communication among participants in order to generate data (Kitzinger 1995). A focus group, normally about 6-10 people, takes advantage of the interaction among a small group of homogeneous people (for e.g. men with erectile dysfunction). Participants will respond to and build on what others in the group have said. The moderator skillfully guides the discussion based on a set of guidelines. Focus group discussion provides access to how knowledge and opinions are formed in social context (e.g. health promotion), generating hypotheses based on participants' insights, developing interview schedules and questionnaires, and evaluating different research sites or study population. Focus groups are useful either as a self-contained means of collecting data or as a supplement to both quantitative and other qualitative methods.

Qualitative Data Analysis

Qualitative data analysis is an on-going process during research involving continual reflection and exploration about the data categorizing of data (patterns or themes emerging) and verification of data, reliability and validity. Data collection and data analysis goes hand-in-hand in qualitative research, and there is no one correct way of interpreting the data. Like quantitative analysis software, qualitative design also has it own data analysis software, such as the ATLAS.ti, Ethnograph, HyperRESEACH, HyperQual, NUD*IST, NVIVO and so forth. These computer softwares can help organize the voluminous amount of data collected in qualitative research.

Conclusions

Qualitative research is fast becoming a mainstream research methodology in health research. Qualitative research has much to offer not only in the area of sexual health, but also other field of research interests. However, it lacks the ability to generalize to the population but capable of generalizing to the theory. Nevertheless, great potential can be derived from combining both qualitative and quantitative research design (mixed-method approach). Whether to employ a qualitative or a quantitative research method depends on the research questions. Both methods complement each other and no one is more superior to the other.

References

1. Holloway I. Qualitative Research in Health Care. Berkshire, Open University Press, 2005.
2. Patton MQ. Qualitative Evaluation and Research Methods. London: Sage, 1990.
3. Kitzinger J. Introducing focus groups. Br Med J. 1995; 311: 299-302.
4. Donovan J, Sanders C. Key issues in the analysis of qualitative data in health services research. In: Bowling A and Ebrahim S (eds.). Handbook of Health Research Methods. Berkshire: Open University Press 2005, pp 515-532.
5. 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): 133-151.
6. Guzman GA, Snow R, Aitken I. Preferences for contraceptive attributes; voices of women in Ciudad Juares, Mexico. Int. Fam Plann Perspect 1997; 23(2): 52-58.
7. Dyers SJ, Abrahams N, Hoffman M, et. al. Infertility in South Africa: women's reproductive health knowledge and treatment seeking behavior for involuntary childlessness. Hum Reprod 2002; 17(6): 1657-1662.
8. Schuler SR, Bates LM, Islam MK. The persistence of a service delivery “culture”: findings from a qualitative studying Bangladesh. Int Fam Plann Perspect 2001; 27 (4): 194-200.
9. Ng CJ, Low WY, Tan NC, Choo WY. The role of general practitioners in the management of erectile dysfunction - a qualitative study. Int J Impot Res 2004; 16: 60-63
10. Low WY., Ng CJ., Choo WY, Tan HM. How do men perceive erectile dysfunction and its treatment? A qualitative study on opinions of men. Aging Male, Sept 2006; 9(3): 175-180.

Note: This paper was presented at the 2nd Scientific Conference of the Asia Pacific Society for Sexual Medicine (APSSM) and the 1st National Congress of the Aging, Gender, Andrology and the Sexual (Sciences) of India (AGASSI), Mumbai, India, 3rd December 2006.