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Indian Journal of Community Medicine

Overcoming the Information Knowlege Gap in Biomedical Research Through Methodological Pluralism

Author(s): R.K. Sachar

Vol. 26, No. 2 (2001-04 - 2001-06)

Dept. of Community Medicine, Dayanand Medical College & Hospital, Ludhiana

Respected Chairperson, Esteemed Colleagues, Dear Friends, Ladies and Gentlemen!

I am grateful to the Indian Association of Preventive and Social Medicine for having bestowed this great honour on me by awarding Dr. Harcharan Singh Oration award. It is a special privilege to deliver this Oration since Dr. Harcharan Singh, as you all know has been one of the leading and most recognised stalwarts of our discipline. Most of us can only dream of what he has achieved in his life time.

I dedicate this oration to my late parents and to my family who have always been a constant source of inspiration and strength.

More than sixty years ago Elliot lamented "Where is the knowledge we have lost in information? Where is the understanding we have lost in knowledge?" In the present day context his words sound almost prophetic. Most of us in the health science sector are painfully aware of our new affliction - the information overload without commensurate increase in knowledge and understanding. The situation is even more acute in the field of biomedical research where the information - understanding gap is greater than ever before. One of the chief reasons for this gap is the lack of methodological pluralism in research, with the quantitative and experimental methods being the sole dominants. The almost sole recognition given to quantitative methods by the researchers and the near total neglect of qualitative approach has made research in biomedical science a "Science of observation" rather than a "Science of implementation".

Let us examine some of the reasons for this dominance. Research tends to be taken seriously if the results or findings are expressed in the numerical form. If something can be counted or measured it gains scientific credibility over the unmeasurable. Because of this, a research finding is more likely to be accepted as a fact if it has been quantified, rather than if it has been not. Quantitative methods have emerged from a "Reductionist" strategy aimed at obtaining objective results i.e. those which are reproducible under similar circumstances and which could predict further events in a situation which was not too dissimilar. Reductionism essentially aimed at attaining objectivity by reducing the dependent variables in a study to minimal. Initially used in research in controlled circumstances (e.g. laboratory or experimental), the reductionist or quantitative strategies came to be used in diverse areas such as in socio-cultural, psychological and even economic issues.

Quantitative methods allow us to make causal inferences by direct observation as in true experiments about the effect of some specific factor (also termed as independent variable) on the outcome of interest (the dependent variable). However, more often than not, the inferences are measured by associations, the strength of which is judged by statistical techniques. In such studies, if confounding and other biases are controlled and the undefined influences are kept to a minimum then the study results are very likely to be highly reliable and have a high predictability about the outcome of the same event in future. In other words, RELIABILITY is one of the main strength of the quantitative methods and follows deductive reasoning. Undoubtedly, reductionist strategies have made an immense contribution in providing infallible insight into the functions and potentials of the various bio-systems. They have also led to the development and refining of the various diagnostic and therapeutic arsenals that we have today in our armamentarium.

However, with the medical advances, increasing emphasis on specialization and the sheer diversity of the health services imply that the health professional today are working in a very complex environment. This complexity in turn generates new and complex research questions. The health system today is a part of the larger social system with which it has a wide and a complicated interface. This has given birth to a new area of research viz. health services (systems) research (HSR). The HSR depends largely on researchers who are basically medically oriented people i.e. doctors, while the majority of the issues confronting the HSR are outside the medical domain and are concerned with client satisfaction, organizational behaviour, community participation and compliance etc. In view of these diverse requirements of HSR in complex settings the explanation for these phenomena can only be obtained by an insight into the affective domain i.e. attitudes, perceptions and behaviour. The methods for such an inquiry clearly involve the use of social science methods, popularly known as the qualitative methods. In fact in today's world, one of the major areas of bio-medical research pertains to human behaviours related to reproduction, sexuality contraception, substance abuse, life styles, consumerism in health etc. All these research requirements cannot be served by quantitative methods alone and require methodological pluralism.

Qualitative research is a pragmatic approach to heath research which necessitates identifying research questions which are likely to contribute to action or change. It aims to provide insight into human factors affecting health and health services. Qualitative methods follow inductive reasoning (i.e. move from observations to hypothesis) and their strength in VALIDITY. The common feature of these methods is that they do not primarily seek to provide quantified answers to research question. Their goal is the development of concepts which help us to understand social phenomenon in its natural (rather than experimental) settings, giving due emphasis to the meanings, experiences and views of all the participants. As a result they are particularly suited to understanding human perceptions, beliefs and practices. Qualitative studies are concerned with answering questions such as "What is X and how does X vary in different circumstances and why?" Rather than "How many Xs are there?" In other words qualitative methods believe in that 'WHAT you count is not WHO I AM'. In view of this, qualitative approaches are best suited to understand complicated human actions which affect their health, like, why many health workers on one hand deliver anti smoking messages but themselves continue to smoke i.e. do not themselves find the relevance of such messages in their own personal lives.

Another very vital area which can be better served by qualitative approach is the field of reproductive and child health. Most reproductive and child health problems are rooted in biomedical dimension yet their origins often lie in human behaviour.

It would now appear that the two methods -quantitative and qualitative are being presented as adversaries in a methodological debate and they are essentially incompatible or mutually exclusive. Nothing could be farther from truth. If we were to view the whole issue dispassionately and take a holistic look, it would seem more fruitful for the relation between the two methods to be characterized as complementary rather than exclusive. Quantitative methods work best when there are a minimum of dependent variables, all under the control of the investigator and when subjects are both homogeneous and passive, but health care deals with people and people are on the whole more complex than the objects of natural science. There is a whole set of questions about human interactions and how people interpret interactions and the health professional needs answers to these. Let us take some real life examples. India's dubious distinction of low female sex ratio is the result of a deep rooted bias against the females but why and how this bias operates at the different levels in the society defies quantitative investigation. Again why in the "granary of India" the rate of low birth weight is as high as twenty five percent and many pregnant women have low energy intakes in spite of plenty of food being available. Further, in one of our recent publications in which we used sophisticated statistical techniques like logistic regression, short birth interval emerged as one of the significant risk factors for perinatal mortality, but the reason why women waste no time in getting pregnant again remained elusive. Experimental and quantitative methods are less well suited to answer these questions while the qualitative methods can fill in this gap quite effectively.

These methods can complement each other in at least three ways. Firstly qualitative work can be undertaken as an essential preliminary to quantitative work. Various qualitative techniques such as in depth interviews or focus group discussion can be used to provide a description or understanding of a situation or behaviour. In health care setting it may relate to practices during pregnancy or child birth, infant feeding practices, immunization dropouts or beliefs regarding foods being hot or cold, or the focus group might even consist of spouses of terminally ill patients and may render invaluable insight for planning a hospice. At their most basic, these techniques can be used simply to discover the most comprehensible terms to be used in a subsequent survey questionnaire. Many a times the terminology in a questionnaire though technically correct is unclear to a sizeable number of the respondents to threaten substantially the overall validity of a response. A preliminary qualitative inquiry may even give a strong pointer towards the right questions to be asked which in turn is very crucial since it is better to have an approximate answer to the right question rather than an exact answer to the wrong question. Classical examples of these are in planning postnatal services to know what the women themselves perceive as postnatal problems or if planning a survey to quantify the gynaecological morbidity, then to know about the local perceptions and names of conditions.

The second way qualitative work can be used is to supplement quantitative work. This can be part of the validation process as in "Triangulation" where three or more methods are used and the results compared with convergence (e.g. a large scale survey, focus groups and a period of observation) or as a part of a multi method approach which examines a particular phenomenon or topic on several different levels. The third way in which qualitative research can complement quantitative work is by independently exploring complex phenomena or areas not amenable to quantitative research. This stand alone approach can be used in reproductive health, family planning or in chronic diseases to answer questions like why do women who desire no more children do not use contraception or why some people default from a drug programme (hypertension, diabetes or tuberculosis).

The qualitative methods like any other method are not without criticism. A problem free methodology if it exists is yet is be found. For the qualitative methods the following problems have been identified to which satisfactory resolutions have not been reached.

- Representativeness, because these methods can take into account only small sample. It has been argued that statistical representativeness is not a key requirement when the object is to understand the social processes.

- Reliability, since collection of data in many forms of qualitative research takes in an unstructured form like tape recordings or transcripts of conversations. Detailed and meticulous maintaining of records can ward off this problem to some extent while the reliability of the analysis can be relatively enhanced by organising an independent assessment of transcripts by additional skilled qualitative researches and comparing agreement between raters.

- Reactivity, since the qualitative field methods involve an extended period of investigator participation in the community. The presence of the investigator can "interrupt" the behavior of the people under observation which has also been termed as the Hawthorne effect. It is also highly desirable that the researcher remains highly objective about the whole issue without getting emotionally involved.

Having accepted that qualitative methods have a definite role in research in biomedical sciences, the question arises as to who should be entrusted with the responsibility of carrying it out. These methods lie in the domain of social sciences and it would seem prudent to include social scientists with an orientation in biology and medicine in the research team. In other words, there is a strong case for having a multi disciplinary research team. Further, to change the firm mind set of the medical researchers, their training in epidemiology and research methodology should include an orientation in qualitative methods. A good beginning point would be to introduce this topic in the post graduate curriculum of community medicine.

Though a detailed description of the various qualitative methods for research is beyond the scope of this talk, an exhaustive list is hereby presented:

(a) Observational methods: Here the researcher systematically watches people and events to find out about behaviours and interactions in natural settings i.e. it is naturalistic research where the researcher acts as the research instrument. It involves 'going into the field or going back stage' and describing and analysing what has actually been seen. This method overcomes the discrepancy between what people say (like in an interview) and what they actually do. The observer's role may vary from one of complete participant carrying out covert observations to being a complete observer and not participating at all. One of its drawbacks is the so-called "HAWTHORNE EFFECT" wherein because of the observation people may modify their behaviour.

(b) Qualitative Interviews: These may be structured, semi-structured, in depth or key informant interviews. They require special skills in the research so that the control of the interview is maintained and the common pitfalls like the interruptions and distractions are kept to a minimum without the interviewer creating a bias by teaching counselling or presenting one's own perspective or getting emotionally involved. Language and translation and back translation are the other problems.

(c) Focus Group Discussions: This technique consists of collecting qualitative data in a relatively rapid manner and gives the basic information about perceptions, concepts and attitudes. The participants talk with each other under the guidance of the facilitator i.e. the researcher.

(d) Consensus methods: Three consensus methods are commonly used, these are the Delphi process, the nominal group or expert panel technique and the consensus development conference. These methods unlike other qualitative methods derive quantitative estimates through qualitative approaches. Their main features are anonymity, iteration, controlled feedback and statistical group response. The problems area is to whom to include as a participant so that collective wisdom rather than collective ignorance is obtained.

(e) Case study evaluation: These are used in evaluation of health services and health policy and often use the process of triangulation to ensure the validity of the findings.

Some of the other methods are:

- The mystery (or simulated) client technique.
- Rapid appraisal procedures including the rapid rural appraisal.
- Focussed ethnographic studies.
- Situational & policy analysis.
- Political mapping, wealth ranking, seasonal analysis and time lines and trends.
- Rashomon technique.

Analysis of qualitative data is a herculean task and currently number of softwares like ANTHROPAC, NUDIST (non numerical unstructured data indexing searching and theorizing) and SPSSx are available for analyzing qualitative data. The complexity of the analysis again reiterates the importance of having specially trained personnel for doing this work, otherwise, since it is fashionable now a days to do qualitative research, many untrained workers have tried to jump for the band wagon of qualitative research, the result being numerous poorly conducted studies.

Finally once the qualitative methods are firmly and scientifically established in our research methodology the medical knowledge will greatly advance and hopefully the information understanding gap will narrow down.

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