Post-Print

This is a pre-copyedited, author-produced PDF of an article accepted for publication in the NSW Public Health
Bulletin following peer review. The definitive publisher-authenticated version [Carter SM, Ritchie JE and
Sainsbury P. Doing good qualitative research in public health: not as easy as it looks. NSW Public Health
Bulletin 2009;20(7–8):1-6] is available online at http://dx.doi.org/10.1071/NB09018

Doing good qualitative research in public health: not as easy as it

looks
Stacy M. Carter, Jan E. Ritchie, Peter Sainsbury (2008)

Corresponding author: [email protected]

Abstract

In this paper, we discuss qualitative research for public health professionals. Quality
matters in qualitative research, but the principles by which it is judged are critically
different from those used to judge epidemiology. Compared to quantitative research, good
quality qualitative studies serve different aims, answer distinct research questions and have
their own logic for sampling, data collection and analysis. There is, however, no need for
antagonism between qualitative research and epidemiology; the two are complementary.
With theoretical and methodological guidance from experienced qualitative researchers,
public health professionals can learn how to make the most of qualitative research for
themselves.

On qualitative research and public health

This issue of the NSW Public Health Bulletin presents examples of qualitative enquiry in
public health. To introduce these papers, we will make some arguments about qualitative
enquiry. What is ‘good’ qualitative research? What is ‘poor’ qualitative research? How can
we tell the difference? Why does it matter? How can you improve the quality of the
qualitative research you commission or conduct?

Qualitative research is at a high-point of popularity in public health in Australia. As a rough

and limited metric, we searched Medline on 19 June 2009 using the search string
((qualitative research.mp. OR Qualitative Research/ OR qualitative method*.mp. OR
qualitative stud*.mp.) AND exp Public Health/ AND (australia.mp. or exp Australia/)). This
search returned no hits before 1990, 57 papers published between 1991 and 2000, and 640
papers for the period 2001 to 2009. You might expect that, as qualitative researchers, we
would be celebrating! Rather, we have shared concerns that the new-found popularity of
qualitative research in public health and health services might be its downfall. We worry
that it may produce so much slipshod qualitative research that audiences lose faith in it as a

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genre, either because the work self-evidently fails to be useful or illuminating, or because
its authors are unable to defend it.

Danger lurks in the illusion that ‘anyone can do’ qualitative research. Epidemiological
research is difficult for novices to do unsupervised. Complex statistics are more or less
unapproachable without formal training, likewise the sophisticated epidemiological designs
required for publication in mainstream public health journals. In contrast, anyone who
speaks a language can have a conversation with someone, write about it and call it
research. This can lead to a proliferation of work calling itself qualitative research that bears
little resemblance to the best practices in the field.

In this editorial, we describe what we mean by good qualitative research. As most of the
studies the Bulletin publishes are epidemiological, we will organise our discussion by
comparing epidemiological and qualitative principles. We will also focus on particular
problems we have observed in the public health and health services literatures.

The papers in this issue

This special issue of the Bulletin contains three peer-reviewed papers and the reflections of
a participant in one of the reported studies. The authors were invited because each was
working in a different substantive area of public health, and in a different methodological
style. We are not arguing that these are the best or only ways of working. However, the
resulting papers provide opportunities to draw out some important issues in qualitative
research practice.

Julie Mooney-Somers and Lisa Maher detail a community-based participatory research

(CBPR) project about bloodborne viruses and sexually transmissible infections. This project
was conducted in collaboration with young Aboriginal and Torres Strait Islander people and
their networks in three communities. CBPR seeks immediate benefit for participants: in this
case, through the development of research capacity, building new links between
community organisations and research institutions, and prioritising ethical and social
considerations.1 CBPR also prioritises a two-way learning process between researchers and
participants. In a commentary attached to the paper, Robert Scott, a participant in the
CBPR project, reflects on his experience of the process and the impact in his community.

In the second paper, Julie Leask reports on a project using role play to examine a critical
moment in GP-patient communication: when a parent refuses immunisation for their
child.2

In the final paper, Jenny Lewis combines qualitative and quantitative methods to ask: ‘Who
is regarded as influential and what issues are considered important or difficult in health
policy?’3 Already you can see some of the diversity in qualitative research practice,
diversity that is highly relevant to our next question.

What is good quality qualitative research?

For epidemiologists, gold standards for good quality research are clear. Population-based
random samples, random double-blind allocation in intervention trials, valid and reliable

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instruments, appropriate statistical tests – all of these are shared ideals. Study types are
clearly defined: case-control studies, cohort studies and randomised controlled trials each
follow a well-known formula and conform to an increasingly well-articulated set of rules.
However, the ‘rules’ for assessing the quality of qualitative research are less
straightforward. There is a large, divided body of work on this subject.4–10 Some seek to
develop standardised rules for qualitative research and/or its reporting; others emphasise
the need for flexibility and accountability from researchers rather than adherence to rigid
principles.4,11,12 It would be simplistic to attempt to provide a standard ‘formula’ for
conducting qualitative enquiry here: instead we will outline some basic principles.

Qualitative aims, research questions and general approach

Qualitative research achieves aims different from and complementary to those addressed
in epidemiology.13 It does this by approaching enquiry differently: through a less
controlled, more open study design, by asking different kinds of research questions and by
employing different ways of thinking.

Descriptive epidemiology asks questions about prevalence and its patterning. How many
children are immunised? Are they unequally distributed by region? Is immunisation
associated with level of education? Qualitative researchers attempt to understand what
happens in participants’ everyday lives, how things work and what things mean to
participants. Leask’s study, for example, asks about a process: ‘How do doctors deal with a
parent who is refusing immunisation?’ Another qualitative study might ask: ‘What does it
mean to a parent to have their child immunised?’ Epidemiological research studies
variables pre-determined by the researcher. Variables of interest must be clearly defined
before data collection starts. Qualitative researchers rarely presume which variables are
important, but rather seek to discover what is relevant by speaking with participants,
reading texts or observing behaviours. Qualitative studies are typically far less controlled
than in epidemiology, certainly markedly less than a randomised controlled trial.
Qualitative researchers seek to study the social world in its ordinary, complicated, changing
state.

Epidemiological logic emphasises linearity and deductive thinking; in its idealised form,
epidemiology begins with hypotheses and makes observations to test these hypotheses.14
Qualitative researchers begin with induction: making observations to build theory, rather
than to test theory. Then, as analysis progresses, they rely on abduction (moments of
inspiration in which a hunch, clue, metaphor, explanation or pattern is imagined or recalled
from existing theory to make sense of the data) and deduction (when the analyst goes back
to the data to test these emerging ideas).14,15 These forms of thinking create a continuous
cycle of data collection and analysis.

In short, because qualitative researchers generally do not know what is important before
they start, their studies are likely to be a lot more flexible than epidemiological studies,
evolving to pursue new leads as they emerge in data collection and continuous analysis.

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Qualitative sampling strategies

A misunderstanding of the aims of qualitative research often leads to poor sampling in

qualitative studies. In epidemiology, we wish to report prevalence of or association
between variables in a defined population. We need to isolate those variables to prevent
confounding. To achieve this, we ideally randomly select participants from the population;
in intervention studies, we also randomise participants into different study arms. We collect
and tabulate data on many variables, including demographic variables. The purpose is two-
fold. The first purpose is to demonstrate that the participants could have been anybody in
the population under study. They had the same chance of being selected or ending up in
the intervention arm as everyone else; there was nothing special about them that could
have confounded the results. The second purpose is to allow the researcher to statistically
control for everything other than the variable of interest.

This is precisely the opposite of the logic of qualitative sampling: in fact, some qualitative
researchers talk about participant ‘selection’ to distinguish it more clearly from probability
sampling.16 In good qualitative research, participants are not ‘average’ or ‘typical’. They
are special. They are selected because they are uniquely positioned to help the researcher
understand what happens or what things mean. Thus, qualitative sampling is often
described as ‘purposive’; that is, chosen to serve an analytic purpose. Qualitative
researchers can learn as much from atypical cases (by comparison and contrast) or from
unexpected sources as they can from central cases or obvious sources. A cleaner may be
able to tell you as much about pandemic control as a nurse, albeit from a different
perspective. Someone who comes to work with influenza may help you understand the
process of staying home when infected. In Leask’s study, for example, GPs known to have
an interest in immunisation or expected to have unusual views about immunisation were
included, as were parents of young children.2 Lewis describes using an empirically
generated map of policy makers’ reputations as a basis for selecting interviewees.3 She
identified eight groups of influential people. Some groups were widely considered
important, others marginal. Lewis’s qualitative sampling included people from each group,
thus providing a range of central and peripheral players with different kinds of expertise or
disciplinary focus. Such sampling (along with the style of data collection) allows for a wide
range of relevant concepts to emerge, and for examination, rather than control, of the
relationship between them.

It is a terrible waste of qualitative research resources to hear exactly the same thing from
30 ‘average’ people who are, for the purposes of the study, identical. This does little to
advance the complexity or depth of the researchers’ understanding. The best qualitative
samples are often determined in a dynamic way as the study progresses, the researcher
constantly asking themselves questions such as: ‘Which new participants could help me
better understand this important idea or process that I am starting to see in my analysis?
What new questions might I ask my existing participants to help me understand? What
might I need to observe to understand? What documents might help me understand?’ This
dynamism requires ongoing modification of ethics approval, but in our experience Human
Research Ethics Committees increasingly expect such modifications in qualitative studies,
and are efficient in processing them.

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Qualitative data collection methods

If qualitative research is to understand what happens and what things mean, generate new
and relevant concepts, and find out what is important to participants (rather than impose
pre-determined variables), then data must be collected in a relatively open way. A large
number of highly structured questions will generally produce yes/no or one-line answers
that yield little insight. Mooney-Somers and Maher’s description of the data collection in
their CBPR project provides one alternative.1 Peer researchers spent time in the
participating communities getting to know people, and this yielded important information
despite being relatively informal and unstructured. Interviews were flexible and personal,
commencing with the origins of both the peer researcher’s and participant’s families and
with the participant’s history, proceeding to the participant’s own stories about their
experience. This kind of open data gathering maximises the chance that important,
unexpected insights will be developed.

Qualitative data analysis

Analysis is a neglected area of qualitative research in public health and health services.
There is generally scant description of analytic methods and reasoning in published papers.
Researchers often appear to do nothing more than magically intuit and then list ‘themes’
from their data. Leask provides one alternative in her paper, making a detailed account of
her analytic processes. Rather than simply stating that she generated ‘themes’, she
specifies that she attended to the rhetorical styles used by the doctors (e.g. giving ‘yes but’
responses, or engaging in ‘scientific ping pong’).2 Rather than focusing on counting the
number of doctors who used each strategy, her analysis explains the detail of each strategy,
including how they worked rhetorically in the simulated consultation.

We would argue that the best qualitative research is oriented less toward generating theme
lists and counting occurrence, and more toward understanding what things mean and how
they work. Experienced qualitative researchers generally use more subtle indicators of
importance than counting. How passionately was something spoken of? What was
unspoken or unable to be said? Who said what? How can we better understand the
differences? What might these differences tell us about the process we are studying? How
rich and complex was a concept? What consequences did participants describe in relation
to it? If, for example, only a small number of people described a problem in a health
service, but they described it as so profoundly undermining their faith in clinicians and the
system that they would no longer attend, this may be a problem worth exploring with more
participants, in order to better understand it.

Box 1. Suggested references for beginning qualitative research

Books and reports to introduce the field

 Mason J. Qualitative researching. 2nd ed. London: Sage Publications; 2002.
 Patton MQ. Qualitative research & evaluation methods. 3rd ed. Thousand Oaks, CA: Sage
Publications; 2001.
 The SAGE Qualitative Research Kit. London: Sage Publications; 2007.

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  Silverman D. Doing qualitative research: a practical handbook. 2nd ed. London: Sage
Publications; 2005.
 Australian Government, National Health and Medical Research Council, Australian Research
Council, Australian Vice-Chancellors Committee. National Statement on Ethical Conduct in
Human Research. Canberra: Australian Government; 2007.
Series in the medical literature
There have been several useful series published in the medical literature in recent years.
The 1995 British Medical Journal series
 This series introduces qualitative research and focuses on data collection methods.
 Jones R. Why do qualitative research? BMJ1995; 311(6996): 42–5.
 Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to
qualitative methods in health and health services research. BMJ1995; 311(6996): 2.
 Britten N. Qualitative research: qualitative interviews in medical-research. BMJ1995;
311(6999): 251–3.
 Kitzinger J. Qualitative research: introducing focus groups. BMJ1995; 311(7000): 299–302.
 Mays N, Pope C. Qualitative research: observational methods in health-care settings.
BMJ1995; 311(6998): 182–4.
 Mays N, Pope C. Qualitative research: rigour and qualitative research. BMJ1995; 311(6997):
109–12.
The 2008 British Medical Journal series
This series focuses on quality assessment, use of theory, and extant qualitative methodologies.
 Kuper A, Reeves S, Levinson W. Qualitative research: an introduction to reading and
appraising qualitative research. BMJ2008; 337(7666): 404–9.
 Lingard L, Albert M, Levinson W. Qualitative research: grounded theory, mixed methods,
and action research. BMJ 2008; 337(7667): 459–61.
 Reeves S, Kuper A, Hodges BD. Qualitative research: qualitative research methodologies –
ethnography. BMJ2008; 337(7668):512–4.
 Reeves S, Albert M, Kuper A, Hodges B. Qualitative research: why use theories in qualitative
research? BMJ 2008; 337(7670): 631–4.
 Kuper A, Lingard L, Levinson W. Qualitative research: critically appraising qualitative
research. BMJ 2008; 337(7671): 687–9.
From the Medical Journal of Australia
Kitto SC, Chesters J, Grbich C. Quality in qualitative research: Criteria for authors and assessors in the
submission and assessment of qualitative research articles for the Medical Journal of Australia. Med
J Aust2008; 188(4): 243–6.

One qualitative alternative to an emphasis on frequency counts is the concept of

‘saturation’. Experienced qualitative researchers generally seek to ‘saturate’ concepts: that
is, to ensure that they have enough data to make a full and detailed account of the
concepts that are central in their analysis.17,18 Flexibility in sampling allows qualitative
researchers to return to the field to collect more data until they reach this point. The logic
underpinning this strategy is: keep talking with the most informative people until you have
a good understanding of how things work and what they mean. This differs from the
alternative logic: list the topics that most people agreed with. Exploratory analytic logic is a

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good match for purposive sampling; frequency count logic is better matched to well-
designed quantitative research using probability sampling.

Reporting and methodology in qualitative research

It is important in any research to distinguish between methodology and methods. Methods

are the actions you take in a research project. Method is what you do: your sampling, your
data collection, your analysis. Methodology is justification of your methods.19 You engage
in methodology for yourself throughout a study, examining each choice you make and
thinking about whether it is justified in relation to your study as it evolves. You also engage
in methodology when you report a study for an audience and justify the methods you have
used to them.

There is rarely adequate attention given to methodology in qualitative research papers, a

problem widely acknowledged and not confined to public health or health services
research. If authors do not justify their methods, it is difficult to determine the quality of
their work. The critical question to ask oneself when engaging in methodology for others is:
‘What would a reader need to know to be able to evaluate my research for themselves?
Which parts of my thinking and methods do I need to explain?’

This is not a matter of apologising for one’s research; conversely, it means arguing for its
usefulness. This goes to the heart of the debate about what good quality qualitative
research is. It is often a difficult argument for epidemiologically trained people to make,
because the methodology of epidemiology is so different from the methodology of
qualitative research. However, as Lucy Yardley argues:

While traditional criteria for research quality are often inappropriate, and the ethos and
plurality of many qualitative methods are incompatible with fixed, universal procedures and
standards, some way of evaluating the quality of research employing qualitative methods is
absolutely necessary, in both senses of the word – both imperative and unavoidable. All
interpretations contain an implicit claim of authority; it makes no sense to engage in a
process of analysis and then deny that it has any validity!4

Qualitative research is time-consuming. Why would you recruit participants, collect data
and go through the lengthy agonies of analysis, only to say apologetically, in keeping with
epidemiological principles: ‘but of course the sample size is very small and you can’t
generalise’? Many novices make these apologies and attempt to make their qualitative
research look as ‘epidemiological’ as possible. Think about sampling. We sometimes see
tables of standard demographics in methods sections of qualitative papers, purporting to
demonstrate how much like the general population the sample were. The fault for this does
not always lie with authors: sometimes editors or reviewers demand such details as a
condition of publication. Not only are such demographics unlikely to satisfy the
requirements of epidemiology, but also, as you will remember, they are inconsistent with
the principles of purposive participant selection. If you succeed in ‘proving’ that your
participants were ‘average’ or ‘typical’, rather than especially relevant to your research
question and analysis, you will probably thereby demonstrate that your sampling was
misdirected.

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Rather than engaging in a doomed attempt to conform to epidemiological standards, a
qualitative methodologist should justify, in detail, aims, research questions and how they
evolved, assumptions made and theories drawn on, sample selected, data collection and
analysis procedures, and the evolving ethical aspects of a study. In relation to sampling,
there should be a detailed account of exactly who was included and, critically, an
explanation of how each group was relevant to the research question and the analysis.20
The contributors to this issue have provided some illustrations of this logic. When Leask, for
example, provides a detailed account of her analytic methods, and presents and explains a
‘negative case’ – a doctor who had a different approach to dealing with the mother who
refused immunisation – she is doing methodological work for you as the reader.2 Mooney-
Somers and Maher, similarly, do methodological work when they explain that their
interview questions were developed in conversation with participants and were designed to
respect cultural protocols, and that this was guided by the principles underlying the study.1

A brief note about existing qualitative methodologies. There are a number of

methodological traditions in qualitative research – coherent ways of working that have
been honed and reiterated over time. They include ethnography, grounded theory,
phenomenology and narrative methodology.21 CBPR, illustrated in this issue, is another of
these extant methodologies. Each of them is a terrific set of resources that can be used to
guide a research project. Each of them has existed and been evolving for decades –
sometimes more than a century. Each of them has considerable, complex theoretical
substance. There is a tendency to slap methodological labels – especially the label
‘grounded theory’ – on anything qualitative, as a kind of badge of authenticity.12,22 This is
a little like going on a harbour cruise for palaeontologists and claiming to be an expert on
the Permian–Triassic extinction event, when in fact you have just read a pamphlet about
dinosaurs from the Australian Museum. It will become obvious fairly quickly that you do not
know your marine organisms from your terrestrial invertebrates, and you will not be able to
get off the boat for at least 4 hours. Traditions such as grounded theory are only useful if
used actively and coherently throughout a study – to help one engage in methodology for
oneself. It is only then that it makes sense to use the label when engaging in methodology
for others.

The conceptual underpinnings of research: reclaiming theory

Karl Popper, the great philosopher of science responsible for the notion of falsification,
famously said that he did not care where scientists got their ideas from: the origin of ideas
was a matter for psychology.14 All that mattered to science was the transformation of
ideas into hypotheses and the deductive testing that followed. This may help explain a
somewhat unfavourable view of theory among some public health researchers.

We think ‘theoretical’ should be reclaimed as a compliment! ‘Being theoretical’ or ‘doing

theory’ means contributing to a cohesive explanation of some aspect of our world. This is
the highest possible purpose of research – far greater than the distillation of lonely facts.
Theory is also inescapable, along with the baggage of values that theory carries. In fact, the
variables in an epidemiological study are a reduction of complex values and theoretical
concepts. If, in epidemiology, we classify a person according to their ‘race’ rather than their

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‘ethnicity’, their ‘culture’, their ‘language spoken at home’ or the amount of ‘cultural
capital’ they have access to, a theoretical choice has been made, whether or not it is
acknowledged. When we treat an individual as independent in analysis, measuring nothing
to do with the society, communities or cultures of which they are a part, we are making a
theoretically loaded choice.

Because of its open, inductive approach to the world, qualitative research is extremely
good at generating new theories. The best qualitative research will also be knowingly
informed by theories of many kinds. Theories provide concepts to use in analysis. They
guide study design: encouraging focus on groups (like cultures or subcultures) or on
individuals; describing in detail or building a conceptual model.21 Theories inform data
creation. When you record an interview, for example, what have you recorded? People’s
experiences? Their attitudes? Their beliefs? Their perceptions? Their performances?23
Would these be the same in any interview, or would they be different at different times and
with different interviewers? What effect do you have in the study, and how should you best
be accountable for this effect? Even the way we write is a theoretically loaded choice. Our
use of an active first person voice and of authors’ first names in this editorial, for example,
reveals our belief that researchers should present themselves as real live human
individuals, rather than ‘objective’, distant and inscrutable, as any piece of research or
writing is a product of the people who have crafted it. Theories are everywhere, and good
researchers of all kinds acknowledge them and use them as resources.24

Lewis argues that the theories about policy that you bring to a study of policy influence will
change what you look at.3 If you use a theory that suggests that influence rests in
institutions, you will examine institutions; if in conflicting interests, you will study interests;
if in contests of ideas, you will study the movement of ideas. These are not right or wrong,
but different, and it is possible to be open to participants’ perspectives within each frame.
Mooney-Somers and Maher’s paper, like most CBPR, also begins with normative theoretical
commitments about what research should be.1 Because of its theoretical orientation, CBPR
defines good research as that which includes participants as equals and achieves concrete
change in participants’ communities, a theoretical commitment that prompted Scott’s
contribution to the issue.

In conclusion: does the qualitative/quantitative distinction matter?

Do we need to make a distinction between qualitative and quantitative research? We

would argue that we need distinction without antagonism: a kind of cross-cultural
understanding and mutual respect. Qualitative and quantitative research can contribute
differently and equally to knowledge in public health and health services.13 However, if
qualitative research is to keep its end of this bargain, it may need to be protected from its
new-found popularity and allowed to assert and follow its own principles. We would urge
those with a nascent interest in qualitative research not to attempt to take it up as a
straightforward, instrumental toolbox of methods. To public health audiences, qualitative
research may seem new; in fact, the ideas at its heart go back centuries, some say as far as
Aristotle.25,26 The methods of contemporary qualitative research were initiated in
anthropology and sociology at the turn of the 20th century and have been evolving ever

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since.27,28 Good qualitative research requires careful thought about methodology and
theory in the context of this history, which is difficult for beginners to achieve without
support and training. We advise public health professionals to work with experienced
qualitative researchers until they have established themselves in this new world.

Qualitative enquiry is a fractured, rich and potentially highly rewarding field of endeavour:
this issue of the Bulletin is a tiny part of it. Public health, we believe, needs both
epidemiology and qualitative research. Without epidemiology we cannot answer questions
about the prevalence of and association between health determinants and outcomes.
Without qualitative enquiry, it is difficult to explain how individuals interpret health and
illness in their everyday lives, or to understand the complex workings of the social, cultural
and institutional systems that are central to our health and wellbeing. We hope that this
issue of the Bulletin will stimulate debate about the place of qualitative enquiry in public
health and health services research in Australia. At the very least, it might prevent you from
getting stuck on a metaphoric harbour cruise with only a pamphlet for company.

Acknowledgements

Our sincere thanks to the authors for their contributions to this issue of the Bulletin.

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