Qualitative research in dentistry helps us make sense of human experience with respect to oral health. It can describe and explain social and cultural influences on health care and develop explanatory theories about those. Pimarily, it explores human-oriented problems about which little is known – thus, the tools of qualitative research help us find out what people are thinking and feeling about something, but not how many people think and feel that way.
Qualitative and quantitative research are dramatically different. In qualitative research, because it’s investigating something that we don’t know much about, the hypothesis is not clear at the beginning of the research process. Similarly, the means of collecting data may change as learning occurs. Few numbers and percentages are reported, because they are not the prime focus of the research. Finally, rather than collecting data from a pre-arranged number of subjects as we do in quantitative research, we stop collecting data in qualitative research only when quit gaining new information. The goal is not for the researcher to be objective, but for him or her to deeply enter the subjects’ world and understand it from the inside.
We’ll talk about 3 theoretical approaches to qualitative research: grounded theory, ethnography, and phenomenology.
The primary purpose of grounded theory is to generate theories of human behavior. But theory does not create the research – rather, it emerges from what subjects do and say.
Ethnography tends to rely on in-person observations and field notes. Other forms of qualitative research rely more on interviews of various kinds. They may be in-depth, one-on-one interviews with key informants, or interviews with groups called focus groups.
Interviews form a flexible and powerful tool for qualitative exploration. They have three main types: structured, semi-structured, and in-depth. Structured questionnaires consists of questions asked by trained interviewers in standard manner. They are actually not a part of qualitative research, but they may be conducted in person.
In semi-structured interviews, the interviewer asks open-ended questions that define the areas to be explored. The questions may vary from interview to interview depending on the information disclosed by the subject. In-depth interviews probe one or two issues in detail. Their questions are mostly based on interviewees’ replies to being asked about the issues under investigation. There are various ways of recording interviews. Notes can be written at the time (if you are a fast writer) or afterwards. The best thing to do is audio- or video-tape the interview. Or have a second person take detailed notes. Then you can devote all your attention to the interview process itself.
Interviews rely on open ended questions to assess factors such as behavior or experience, opinion or belief, feelings, knowledge, and even demographic information.
Key informants are especially good persons to interview in qualitative research. They are persons who are part of the community in question and who are considered by community members to be knowledgeable on the particular topic. They must be willing to share this information. Informants can help identify other informants.
One-on-one interviews are best when the topic in question is sensitive and people aren’t likely to share in a group. But if additional persons are likely to stimulate the sharing of richer information, then a focus group is called for. Focus groups are relatively homogenous groups in which individuals share ideas about a topic. They typically contain 7 to 10 members. More than one focus group is usually planned to obtain a diversity of opinion. What is said in the groups is transcribed and analyzed
Qualitative data collection results in a large volume of data – consisting of everything that was said and done in the interviews and focus groups. This data needs to be reduced or boiled down to its most important elements. Sometimes diagrams and figures help to organize the data, just as graphs do in quantitative research. Based on these important elements and relationships, conclusions are drawn.
Data reduction primarily consists of identifying the important themes in the data. What is said about each theme is then compared and contrasted according to who is speaking. For instance, patients who are immigrants may believe one thing, and patients who were born in the US may believe another. Being able to contrast these beliefs could be important to patient compliance. The researchers then draw conclusions based on the comparisons and contrasts within the various themes.
The study’s conclusions often note regularities, patterns, explanations, and causal factors related to the theme of the research. The researchers maintain openness and skepticism as they collect their data. Because the data analysis is occurring while the data collection progresses, the study’s conclusions become clearer as it progresses. The researchers can then test meanings and themes for validity as they go.
In some ways the structure of qualitative data analysis is very much like that of quantitative analysis. Qualitative data reduction is equivalent to computing means and standard deviations in quantitative research. Data display is similar to creating tables, graphs, and charts. The overall conclusions of qualitative research are similar to quantitative research’s p values and the differences reported between the experimental and control groups.
Julliard Diversity Presentation 2013
Developing Diversity- Oriented QualitativeResearch in Community Health Care Settings Kell Julliard, MA Lutheran Medical Center Brooklyn, New York
Qualitative Research Methodology• Makes sense of human experience• Describes and explains social and cultural influences• Develops explanatory theories• Explores human-oriented problems about which little is known
Differences from quantitative• Quantitative: randomized controlled trials testing a new drug, cohort studies assessing risk factorsQualitative:• Hypothesis not clear at beginning• Means of data collection may change as learning occurs• Few numbers/percentages reported• Stop when quit learning new info• Researcher enters subjects’ world
Grounded theory• Primary purpose: generate theories of human behavior• Theory emerges from what subjects do and say
Methods of Data Gathering• Observation/field notes• Interviews• Key informants• Focus groups
Interviews• Flexible and powerful tool• Three main types: Structured, Semi- structured, and In-depth• Structured – Structured questionnaire asked by trained interviewers in standard manner
Interviews• Good for sensitive topics where need for confidentiality and trust are paramount• Semi-structured – Open-ended questions that define area to be explored• In-depth – One or two issues covered in detail – Questions are based on interviewees’ reply• Various ways of recording interviews – Notes written at the time or afterwards – Audio or video taping
Interviews• Good open ended questions assess – Behavior or experience – Opinion or belief – Feelings – Knowledge – Demographic information
Key informants• A person residing in the community• Considered by community members to be knowledgeable on topic• Willing to share this information• Each informant identifies other informants
Focus Groups• Relatively homogenous groups• Individuals share ideas about a topic• Purpose: produce honest disclosure – individuals need to build trust quickly so that their sharing stimulates agreement, disagreement, richness of information• Size typically 7 to 10 members• More than one focus group usually planned to obtain diversity of opinion• What is said in the groups is transcribed and analyzed
Qualitative data analysis• Consists of – Data reduction – Data display – Conclusion drawing and verification
Data Reduction• Identify themes in data• Compare and contrast data from each theme• Draw conclusions• Data display: explanatory diagrams, flow charts, causal networks, tables of themes with supporting quotes
Conclusion drawing/Verification• Note regularities, patterns, explanations, causal factors, and propositions• Maintain openness and skepticism• Conclusions become clearer as study progresses• Test meanings for validity as you go
Comparison with quantitative analysis• Data reduction = Computing means, standard deviations• Data display = tables, graphs, charts• Conclusion = p values, experimental and control group differences
99,598 people in Sunset Park (2010 census) Hispanic Chinese White Black Two or more
• All studies reported here were presented at national meetings and published• Only one study received outside funding
Health needs assessment of the Chinese Population in Sunset Park from a holistic perspectiveKhin Kyaw Kyaw Thein, MD, Kyaw Thuya Zaw, MD, Rui-Er Teng, MD, Celia Liang, DO, Kell Julliard, ATR-BC
Team Composition• Two MD volunteers seeking residency• Two Chinese Family Medicine residents needing to fulfill research requirement• Qualitative researcher (KJ)
Resources needed• Time for carrying out study• A variety of IT reports• Administrative support in identifying key informants, interviewees
Introduction• Growing emphasis on cultural competence in health care delivery• SP- bottom 10 of NY neighborhoods• Chinese - 25% of Sunset Park residents• Access to health care for Chinese people is lower than those of other ethnic groups.• Even in the Chinese, disparities exist based on their income, immigration status, social classes, and place of birth.
Introduction (cont.)• Purpose - to identify the health needs of the CPSP from a holistic perspective-physical, social, mental, and spiritual points of view.• 3 parts of the main study: (1) Perception of health needs by Chinese community members (2) Comments on health related issues by health professionals and community leaders (3) Information from electronic databases
Methods• Information from Electronic Databases – LMC – electronic billing data – Infoshare Online – New York City Department of Health and Mental Hygiene – Epidemiology Query Survey data – Asain American Federation of New York• Interviews and FGD with LHC physicians, key administrators and clinicians within LHC system, representatives from BCAA, CPC, American Cancer Society.
Methods (Cont.)• One-on-one interview in Cantonese and Mandarin with Chinese community members: – Total 37 interviews at FHC, private clinics, school, interviewees’ homes, and public places such as restaurants and department stores – Interviewees: 15 to 76 yr, elderly, working age men and women, and an adolescent, living in US from 3 to 20 years and in Sunset Park, 5 months to 20 years.
ResultsThe combined results from three parts of the study: • D = Information from electronic databases • P = Information from health professional and community leaders • C = Information from community membersOrder of presentation includes: • Physical Health • Mental Health • Social Health • Spiritual Health • Health Seeking Behaviors • Health Needs
Physical Health Outpatients – Adults• Normal pregnancy (D)• Hypertension (P, C, D)• Diabetes (P, C, D)• Heart disease (P, C, D)• TB (P, C)• Hepatitis B (P, C)• Peptic ulcer disease (P, D)• Smoking – mostly men (P, C)
Physical Health (Cont.) Top Causes of Death• Heart disease• Cancer• Stroke• Chronic lower respiratory disease (smoking)• Influenza and pneumonia
Mental Health• Is a stigma, so do not discuss (P, C)• Depression (P, C)• Somatization (P) – detection low• High stress (C)• Anxiety (C)• Schizophrenia (C) – high visibility
Social Health Environment• Overcrowding (C)• Theft (C)• Gambling (C)• Prostitution (C)• Dirty streets (C)• Teenage gangs (C)• School absenteeism, dropouts (C)
Social Health (Cont.) Work• Long working hours (C)• Much manual labor (C, D)• Low pay (C)• Lack of job security (C)• Poor work environment (C)• Lack of health insurance (P, C)• Language barriers (C)
Social Health (Cont.) Family• Conflicts over money• Parents lack time to care for children• One parent may work out of state – Child HealthPlus only available in NY• Infants sent to China until school age (P, C)• Cost of childcare higher in US• Lack of family time together
Social Health (Cont.) Family• Children lack supervision• Children lose their Chinese language, culture & tradition – leading to: – Growing cultural gap between generations (P, C) – Miscommunications to no no communication between generations• Because of language problems, parents rely on children for translation• Conflict with in-laws• No consensus on whether the elderly isolated or not (P, C)
Spiritual Issues• Most do not have religious or social support (C)• Christianity (young) and Buddhism (elderly) – main religions (C)• Traditional practices during holidays (C)• Many believe spirituality influences health (C)
Health-seeking behaviors• Preferred western medicine or combined traditional and western (P, C)• Believe antibiotics cure almost all illnesses (P)• Buy antibiotics OTC• Noncompliant with doctors’ advice (P)• Undocumented immigrants don’t seek care – afraid of being reported (P)• Seeking services depends on if they have health insurance (P, C)
Limitations• A small study, not representative of the entire CPSP.• Subjected to individual’s experience and knowledge.• No funding. No incentives for interviewees.• Difficulty to find interviewees who are willing to volunteer their time.• Limited time.• Some Electronic Data – not recent.
Recommendations Need more Chinese speaking health care professionals, especially psychiatric and social services provided in a culturally sensitive way. More education regarding Western health care via Chinese pamphlets, public lectures, health fairs or newspapers. Free screenings. Health professionals also need to be aware of the community members’ beliefs regarding Western medicine versus TCM so that they can better understand them. Poverty creates many social and physical health problems – difficult to solve.
What Latina PatientsDon’t Tell Their Doctors: A Qualitative Study C. Delgado, DO, E. Cruz, MD, J. Vivar MD, J Bellask, H Sabers, and K. Julliard, MA Family Medicine, Internal Medicine, and the Department of Community-Based Programs Lutheran Medical Center 2007
Team Composition• One MD volunteer seeking research experience• Two residents needing to fulfill research requirement – one Internal Medicine, one Family Medicine• Community services support staff member• Medical student• Qualitative researcher (KJ)
Patient Disclosure• Treatment and health affected by what patient chooses to disclose to physician• Culture and gender play important role in what patients disclose• General reasons for nondisclosure in Latina women are not well understood
Goal• To better understand factors contributing to nondisclosure of medical information by Latina patients to their doctors
Methods• Participants – Hispanic women living in Sunset Park – Informed consent obtained – Age 18 years old and older – Primarily clients using services of our Family Support Center
Interviews• In-depth one-on-one interviews• Trained bilingual interviewers• Semi-structured interview guide – Based on Sankar and Jones format• Interviews lasted 30-60 minutes• $25.00 payment for participating
Qualitative Data Analysis• Data = transcribed interviews• Analyzed using a grounded theory approach (theory emerges from data)• Interviewers and authors read transcripts of all interviews and discussed each one• Themes emerged from interview data• Themes were codified into a coherent list
Results• 28 interviews: 6 major themes emerged – Physician-patient relationship – Language barriers – Sensitive issues – Culture differences – Gender and age differences – Time constraints
Physician-Patient Relationship – 26 participants commented on this theme: – Qualities of compassion and Caring • Domestic violence, Death issues, Fertility – Respect and communication skills • Decreased confidence in their doctors • Lied about real symptoms • Couldn’t trust physician with intimate details
Language Barriers– 23 participants commented on this theme– Physician didn’t speak Spanish • Patient couldn’t explain needs • Patient couldn’t understand instructions– Use of translators– Physician didn’t speak understandably • Patient felt inadequate, found help elsewhere
Sensitive Issues– 20 participants mentioned this theme– Sex, sexuality and genital problems • Lied about PAP tests, genital problems– Reproductive issues • Fertility, abortions, STD’s– Violence, abuse and Drugs • Afraid of the repercussions, the law
Culture– 19 participants mentioned this theme– Own cultural beliefs and practice • Sex isn’t discussed in public • Family problems stay in the family– Doctors’ cultural beliefs • Attitudes not conducive to trust • Judgmental attitudes : STD’s, Abortions
Gender and Age Differences– 13 participants mentioned this theme– Age of the physician was less common • Sexuality issues - embarrassing– Gender of the physician more common • Won’t talk about sex with male physician • Won’t talk about reproductive issues • Don’t want to be examined by males
Time Constraints– 7 participants commented on this theme– Visits are too short– Hindered development of doctor/patient relationship– Uncomfortable with their physicians– Doctors cut them off– Don’t listen to their needs– Patients use limited time to hide information
Health Assessment of theArab American Community in Southwest Brooklyn Kell Julliard, Linda Sarsour, Virginia Tong, Omar Jaber, and Mohammed Talbi Arab American Association of New York Lutheran HealthCare Brooklyn, New York
Team Composition• Member of AAANY staff• VP for cultural comptence• Health center Arabic liaison• Arabic college student• Qualitative researcher (KJ)
Community Partners• Arab American Association of New York• New York City Council – modest funding• Lutheran Medical Center• Lutheran Family Health Centers
Resources• Health access, status, and demographic survey created jointly between AAANY and health center• AAANY provided staff to conduct survey and organized presence at events• Health center provided research/survey expertise, training in qualitative and structured survey interviewing, support in scanning survey, data analysis, writing and presenting
Introduction• “Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as a patient’s insurance status and income are controlled.” – Smedley et al, 2002• Arab Americans – part of this low-income group not receiving appropriate health care?
ACCESS surveys suggest• high prevalence of chronic diseases• underuse of health services• limited preventive health practices• ACCESS = Arab Community Center for Economic and Social Services
In the Arab world• Life expectancy – – 62.6 years for men – 65.2 years for women• About 10 years less than for US adults
Objective• To gather basic demographic information about the Arab American community in Brooklyn• To assess members’ perceptions of health status, needs, behaviors, and access to services
Such a survey could provide• Direction for implementing changes in the health care system• More culturally competent care for this population• Improved access to care• Better planning and evaluation of service programs specific to Arab Americans
Lutheran HealthCareLutheran Medical CenterLutheran Family HealthCenters• Arabic-speaking bilingual bicultural staff• Arab patient representative• Free interpretation services• Halal meals available• Onsite Mosque• Signage and written documents in Arabic• Imam on call service
Methods• Study designed and implemented through a collaborative partnership:• Arab American Association of New York (AAANY)• Lutheran HealthCare (LHC)
Surveyl Written in Englishl Translated into Arabic by AAANYl Respondents could be interviewed in either language
Implementationl Survey conducted in April and May of 2008l Interviewers trained in non-biased techniquesl Participants interviewed individuallyl At Arab community gathering places in southwest Brooklynl Convenience sample
Survey respondents• 348 respondents – 200 women – 148 men• Reflected southwest Brooklyn• Most frequent countries of immigration: Egypt, Yemen, Morocco, Palestine• 88% Muslim• 92% primarily spoke Arabic at home• 56% moved to US before 2000
• 58% chose health care venue based on language• The rate of poverty – 42% in this sample of Arab Americans – 16% in southwest Brooklyn overall• No health insurance – 37% who moved to US after 1999 – 21% who moved to US 1999 and before• Almost half of respondents never exercised
Percentage uninsuredl 28% of this sample of Arab Americansl 22% of immigrants in New York City overalll 18% of New York City overalll 18% of Brooklyn overalll 13% of Southwest Brooklyn overall
Foreign-Born vs. US-Born Adults Rating Their Health Status Fair/Poor40 36 31 30 Total30 24 26 Hispanic 2019 2120 16 17 Asian 12 White10 Arab overall0 Black Foreign-born US-born
Comparison of Arab Americans with NYC Overall 45 42 40 35 30 28Percentage 25 22 21 Arab-Americans 20 New York City 15 10 5 0 Living in Poverty Uninsured
Employment (p < 0.001)Men Women 59% employed full time 8% 17% employed part time 10% 17% unemployed 28% 1% homemakers 45%
Smoking in Arab Men vs. Immigrant Men in NYC 45 42 40 35Percentage 30 25 Arab 25 21 Russian 20 Mexican 20 17 Chinese 15 Jamaican 10 5 0 Smoker
Discussionl Compared to other immigrant men and Arab American women in NYC our findings suggest that Arab men in Southwest Brooklyn have a much higher rate of smoking.l Survey assessed cigarette smoking. Numbers of other forms of smoking could be much higher – e.g., hookah smoking.
• The health impact of smoking and poverty on the Arab American community in Southwest Brooklyn is cause for concern.• Future research should quantify these issues more precisely so that effective programs can be designed and funded.
Parental attitudes on feeding, oralhygiene, and dental treatment ofchildren in the Chinese population with Early Childhood Caries- A Qualitative Research Project Diane Wong, D.D.S, Silvia Perez-Spiess and Kell Julliard Lutheran Medical Center, Brooklyn, New York
Team Composition• Pediatric Dentistry resident needing to fulfill research requirement• Experienced pediatric dentist• Qualitative researcher (KJ)
Introduction• Many Chinese children in dental clinic had multiple carious teeth, were diagnosed with Early Childhood Caries (ECC).• Some received dental treatment under general anesthesia or sedation because extensive treatment needed or were uncooperative.• Cultural beliefs and attitudes may affect the development and progression of this problem.
Objective• To learn about the Chinese parents’ unique perspective regarding Early Childhood Caries in their children.• Parents encouraged to share their views regarding oral hygiene habits, cultural beliefs, and attitudes towards dental treatment.• Findings will enable providers to have better understanding and be able to provide more culturally sensitive care.
Methods• Individual interviews with parents• Sample - 20 parents and one grandparent• Each one-hour interview tape-recorded and later transcribed.• Interviews conducted in child’s home or hospital depending on the parents’ preference.• Cantonese, Mandarin, or English language used during the interview.• Each parent - small monetary gift along with toothbrushes and toothpaste.• Interview guide covered oral hygiene and habits, parental attitudes on dental problems, and cultural beliefs regarding dental treatment.
Results – Negative Themes• Fears of dental anesthesia, lack of social support in seeking dental treatment, inadequate knowledge of good oral hygiene and habits, and cultural beliefs that do not support the practice of preserving a healthy primary dentition – Parents think that general anesthesia will negatively affect the development of the child’s brain. – Grandparents scold the parents for allowing their children to have surgery simply to fix baby teeth. – Parents often do not brush their children’s teeth regularly because they did not do so as children. – Friends shocked when see that parents allowed multiple extractions to be done at once. They feel that these procedures are bad for the child.
Positive themes• Trust in the providers, satisfaction with outcome of dental treatment, and improved understanding of oral health. – Parents feel that technology in the Western world is more advanced than in China. They are glad that their children received this dental treatment efficiently in the hospital. – Although many parents use Chinese herbal remedies to address their own dental problems, they most often turn to Western medicine when their children need treatment. – Parents accepted the recommendations given to them by the dentists and they feel that it is important to free their children from dental caries and pain, and maintaining oral health is essential.
Conclusions• Many parents unaware of optimal oral hygiene habits and feeding habits partially because they grew up in a time and place where the society and culture that did not focus on preservation of the primary dentition.• Although many parents expressed fear and concern as their children were in the process of receiving dental care, the majority felt that they had made the right decision in proceeding with the treatment regardless of other people’s negative opinions.• The society including friends, family members, and community bring negative influences to these parents.• Healthcare providers can now anticipate what beliefs common to this community, can better recognize problems and begin intervention at earlier stage.
Recommendations to dental healthcare providers• Provide education (written, verbal or visual) to parents and caregivers on the importance of preserving and maintaining a healthy primary dentition in preferred language.• Understand the parent’s cultural beliefs and backgrounds.• Reassure parents of the benefits that treatment will provide for primary and permanent dentition.• Maintain the importance of good oral hygiene, good diet, and regular recall visits.• Educate Chinese community in general
Our ways of sharing findings of qualitative studies• Annual health system-wide research fair• Departmental conferences• Online newsletter• Task force meetings• Summaries circulated by administration• National and regional conferences
Tips for training interviewers• Schedule dedicated training time• Explain principles• Opportunity for role playing• Simulate actual interview set-up
Tips for Publishing Findings• Pick journal ahead of time• Design study in a way similar to those previously published in journal – Medical journals: theoretical model for research not so important – Academic and social science-oriented journals: require a specific model