Actionable data insights have the power to generate information and prioritize decisions to achieve scalable and sustainable impact. While quantitative data is an important tool, the over-reliance on statistics without using qualitative insights to understand the community or the problem will limit the impact of any social intervention. Qualitative assessments help to improve our understanding of the reasons behind individual/community behaviors. This article is an attempt to highlight the importance of qualitative assessments in social interventions based on my experiences.
Qualitative Assessments in Public Health
Qualitative assessments are important as they help one grasp the “contextual influences, including historical, social, political, or cultural factors” (Jack), that determine the efficiency or inefficacy of interventions and policies. In public health, qualitative studies help by understanding the various aspects such as livelihood, culture, consumption patterns, kinship relations, and health and sanitation practices of the community. This enables a deeper knowing and recording of the social contexts of public health conundrums and will pave a path towards more focused interventions with higher efficacy. Qualitative research findings offer the opportunity to take the subjective experiences of individuals into account. Making space to talk and listen helps to build trust and facilitates “increased communication, collaboration, and goal setting” (Jack) between the individuals and systems such as NGOs and the state.
Qualitative assessments also help one in bringing people’s lived experiences to the decision-making spaces. In Sense and Solidarity: Jholawala Economics for everyone, Jean Dreze emphasizes the importance of fieldwork and experience in understanding developmental issues and formulating policies. Lived experience gives us an enlightened view on the priorities of social policy which helps us put statistical data in perspective. The policies informed by this kind of research can imagine individuals as people with an agency whose participation makes development a collaborative process (Dreze).
At my fellowship placement with India Health Action Trust’s Project MANCH, we are working to improve maternal and newborn health outcomes through community and facility interventions. I was tasked with conducting a qualitative research study to identify and analyze the barriers to access to maternal and newborn healthcare for pregnant women in the above regions. The main tool that I employed for this study was in-depth interviewing. I interviewed 23 women who had given birth in the past six months and 9 frontline workers from three intervention blocks of Shahdol. The research participants were identified from the baseline study conducted by Project MANCH.
Creating space for conversations
In-depth interviewing was selected as a tool to encourage a free-flowing conversation to understand the multiple aspects that shaped the community’s health-seeking behaviors. Qualitative research, especially in-depth interviews necessitate a link to be established between the interviewee and the interviewer. The interviewer must create a friendly and safe space where the women can freely talk about their experiences without fear of shame or judgement. Knowing that nothing encourages a brisk friendship more than sharing a common language, I expected a fair share of obstacles while navigating the rapport-building process. The women I worked with spoke a variation of Hindi with an accent that I had become familiar with over many months.
Surprisingly, what I had considered as a setback initially became the factor that helped me talk to the women in the villages better. Their perception of me was also important as it shaped how they interacted with me. My identity as an outsider made them more trusting and enthusiastic to share their experiences and beliefs with me. In instances where language failed me, body language, gestures and audio cues helped me to create the above-described space.
In this co-created space, I saw multiple emotions- joy, regret, sadness, anger, hopelessness and more. There were numerous instances where the women expected me to have solutions to their problems such as the lack of transport in a village, not receiving money under a government scheme etc. As most of these were manifestations of structural problems, admitting my powerlessness to assure change was uncomfortable. Documenting their words and providing a safe space to talk felt like lesser contributions amidst much bigger problems.
Emotional embeddedness in the community and practising reflexivity
While conducting in-depth interviews, becoming emotionally embedded in the stories of the individuals you work with is an inevitable affair. Emotions are central to building rapport with the participants. However, there has always been anxiety and ambivalence attached to the idea of emotional connectedness in research. Elizabeth Freeman’s “Bringing your whole self-to-research” had become my bible for working through such anxieties and learning about the centrality of emotions to strengthen research.
Paying attention to the emotions that come up during conversations is important. At the same time, it is necessary to also draw attention to the structural and ideological structures that produce these emotions. The presence of these emotions does not compromise the integrity of the research, instead, it empowers us “to write stories that are persuasive, tell narratives that make power and domination visible, and produce research that stirs people deeply and viscerally.” (Freeman)
Reflexivity should be at the centre of all the research processes. A researcher must be aware of the relationship between the research process (from methodology, research questions, and study design to analysis) and the researcher’s values. This reflexivity is important as “research is a process of constructing knowledge; this process is not value-neutral or free from dynamics of power that determine what knowledge counts” (Kendall and Halliday). We must constantly question our own assumptions and preconceived notions that are often in play. This critical reflection process at every stage of the research process ensures accountability in the interpersonal relationships with participants.
Placing these values at the heart of my research practices helped me answer my objectives well. My research study uncovered how multiple factors- structural (economic condition, caste, gender, geography, infrastructural aspects etc), social and psychosocial (perception of care, cultural factors, individual behaviors etc) and health system factors (frontline workers’ perception of their work and approaches, skill set, quality of care at the facility etc), influence access to health services for mothers and new-borns. Multiple stakeholders and systems interact in this journey from the first antenatal care to ensuring the survival of a healthy child and mother. Beyond just availability, we must also think about accessibility, acceptability and quality of care in the backdrop of these social determinants of health.
All the personal interviews ended with me asking the women what their perspective of a solution should be. While the answers seemed simple like having a phone, company or a vehicle, the absence of these is a result of multiple factors. Identifying the root causes of an issue is significant to design interventions that target the problem. This can only be done by working with the community and centering their voices and needs. This qualitative analysis helped me understand the steps that my HO needed to take to bridge the existing gaps and meet the project’s overarching goals.
Only when solutions come from the community can we ensure that it is culturally acceptable, need-driven and sustainable in the long run. Qualitative studies are an extremely useful tool to assess needs, understand the gaps and recognize solutions. By involving the community at every stage, we ensure that communities play a collaborative role in development processes.
Dreze, Jean. Sense and Solidarity: Jholawala Economics for Everyone. Oxford: Oxford University Press, 2017.
Freeman, Elizabeth Hordge. “Bringing Your Whole Self to Research”: The Power of the Researcher’s Body, Emotions and Identities in Ethnography.” International Journal of Qualitative Methods (2018): 1-9.
Jack, Susan M. “Utility of Qualitative Research Findings in Evidence-.” Public Health Nursing (2006): 277-283.
Kendall, Sacha and Lesley E Halliday. “Undertaking ethical qualitative research in public health: are current ethical processes sufficient?” Australian and New Zealand Journal of Public Health (2014): 306-310.