Advancing the Science of Qualitative Research to Promote Health Equity

Abstract

Qualitative methods have long been a part of health education research, but how qualitative approaches advance health equity has not been well described. Qualitative research is an increasingly important methodologic tool to use in efforts to understand, inform, and advance health equity. Qualitative research provides critical insight into the subjective meaning and context of health that can be essential for understanding where and how to intervene to inform health equity research and practice. We describe the larger context for this special theme issue of Health Education & Behavior, provide brief overviews of the 15 articles that comprise the issue, and discuss the promise of qualitative research that seeks to contextualize and illuminate answers to research questions in efforts to promote health equity. We highlight the critical role that qualitative research can play in considering and incorporating a diverse array of contextual information that is difficult to capture in quantitative research.

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https://doi.org/10.1177/1090198117728549
Health Education & Behavior
2017, Vol. 44(5) 673 –676
© 2017 Society for Public
Health Education
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Editorial
In the two decades since former U.S. Surgeon General David
Satcher announced the ambitious goal of eliminating health
disparities by the year 2010, the primary emphasis of health
disparities research has been on describing, documenting,
and quantifying differences that the public health community
has considered problematic. Despite the obvious value of
such research, these efforts rarely offer insight into the com-
plex, layered, and multifaceted social, economic, and politi-
cal factors that shape health disparities. Many scholars have
noted that we have fallen short of the goal of eliminating
disparities (Thomas, Quinn, Butler, Fryer, & Garza, 2011);
the resources invested in these efforts have not yielded com-
mensurate returns in terms of improvements in population
health or the reduction, much less elimination, of health dis-
parities (Shaw-Ridley & Ridley, 2010).
As health disparities have emerged as the metric by which
to measure progress toward achieving health equity
(Braveman, 2014), the field has continued to struggle to
describe unjust yet modifiable differences in health in a way
that will be useful to ongoing efforts to prevent greater health
disparities, improve population health, and move toward
health equity (de Melo-Martin & Intemann, 2007). Health
equity has been defined both as the absence of systematic dis-
parities in health and the determinants of health and “the prin-
ciple underlying a commitment to reduce—and, ultimately
eliminate—disparities in health and in its determinants,
including social determinants” (Braveman, 2014, p. 6). Health
equity has received greater attention in recent years, but some
argue that the emphasis on equity rather than disparities is
merely semantic, while others suggest that the shift in lan-
guage represents progress toward more sustainable, popula-
tion-level solutions and interventions at community, state,
and national levels (Srinivasan & Williams, 2014). In addi-
tion, concurrent with the move away from merely reducing
disparities to promoting equity has been a move from a deficit
model to one capitalizing on community and population
strengths and assets (Bediako & Griffith, 2007; Griffith, Moy,
Reischl, & Dayton, 2006; Srinivasan & Williams, 2014).
Although health education and behavioral researchers and
practitioners have been using qualitative research to inform
their research and practice throughout this time (Steckler,
McLeroy, Goodman, Bird, & McCormick, 1992), how quali-
tative methods are used to facilitate improving population
health or reducing health disparities has not been well docu-
mented. Qualitative methods play an important role in how
we understand and describe the problem of health inequities
and their determinants, and qualitative approaches are
728549HEBXXX10.1177/1090198117728549Health Education & BehaviorGrifth et al.
research-article2017
1Vanderbilt University, Nashville, TN, USA
2Columbia University, New York, NY, USA
3Emory University, Atlanta, GA, USA
Corresponding Author:
Derek M. Griffith, Center for Research on Men’s Health and Center for
Medicine, Health & Society, Vanderbilt University, 2301 Vanderbilt Place,
PMB #401814, Nashville, TN 37240-1814, USA.
Email: derek.griffith@vanderbilt.edu
Advancing the Science of Qualitative
Research to Promote Health Equity
Derek M. Griffith, PhD1, Rachel C. Shelton, ScD, MPH2,
and Michelle C. Kegler, DrPH, MPH3
Abstract
Qualitative methods have long been a part of health education research, but how qualitative approaches advance health equity
has not been well described. Qualitative research is an increasingly important methodologic tool to use in efforts to understand,
inform, and advance health equity. Qualitative research provides critical insight into the subjective meaning and context of
health that can be essential for understanding where and how to intervene to inform health equity research and practice. We
describe the larger context for this special theme issue of Health Education & Behavior, provide brief overviews of the 15 articles
that comprise the issue, and discuss the promise of qualitative research that seeks to contextualize and illuminate answers
to research questions in efforts to promote health equity. We highlight the critical role that qualitative research can play in
considering and incorporating a diverse array of contextual information that is difficult to capture in quantitative research.
Keywords
health behavior, health disparities, qualitative methods, race/ethnicity, social determinants, social ecology, social inequalities

674 Health Education & Behavior 44(5)
uniquely positioned to document and contextualize how
these factors affect health across levels of the social ecologi-
cal framework in a more nuanced and in-depth way.
Qualitative research is meant to offer rich, practical, and
transferable findings that can provide insight into future
research on similar phenomena or among similar popula-
tions. Qualitative approaches to research take into account
the experience of individuals and community and policy
actors and reduce, if not eliminate, the artificial separation
between the research subject and object that limits our ability
to understand the phenomena of interest (Daniels, Hanefeld,
& Marchal, 2017). Qualitative research thus brings into
sharper focus the subjective meaning of health behaviors and
psychosocial determinants of health that have played impor-
tant roles in refining health behavior theory and practice
(Banyard & Miller, 1998), highlighting the social nature of
health and illness, the social construction of knowledge, and
the context of health (Daniels et al., 2016; Thomas et al.,
2011).
Amid this landscape, in recent years, Health Education &
Behavior has experienced a notable increase in the number of
submissions of reports of qualitative research. Noting this
trend, the Health Education & Behavior editorial team believes
that the field has failed to bring critical attention to the unique
role that qualitative theoretical and methodological approaches
to research can play in informing efforts to advance health
equity. This special theme issue of the journal focuses on how
we can use qualitative research to continue to advance research
and practice in health promotion and health behavior change
efforts to achieve health equity. Qualitative research is critical
for providing (a) a more in-depth understanding of the factors
that shape health and behaviors; (b) insight into the processes
through which these factors shape health and disease; (c) a
more contextualized understanding of interventions (e.g.,
what worked, why it worked, how it worked); and (d) oppor-
tunities for theory-building and testing. Consequently, the goal
of the special theme issue is to highlight the rigor of qualitative
methodologies available, as well as the range of contributions
that qualitative research can make to advancing our under-
standing of the determinants of health and how to more effec-
tively move the field toward health equity. This issue builds on
the long history and foundation of qualitative research that
exists in the field of health behavior and the social and behav-
ioral sciences to provide insight into the subjective meaning,
context, and importance of health. And in developing the
issue, we were especially keen to attract articles in response to
the Call for Papers that highlighted the value of qualitative
analytic strategies that may be less common in health educa-
tion and health behavior research, yet offer unique strengths
and promising new insights for informing health equity
research and practice.
Toward that end, Bowleg opens the issue with a trenchant
commentary (“Towards a Critical Health Equity Research
Stance: Why Epistemology and Methodology Matter More
Than Qualitative Methods”), highlighting that qualitative
methods are not inherently progressive but that their use in
the context of a critical health equity research approach and
an understanding of the role that epistemology plays can
advance health equity research.
In an article that represents the Policy, Environmental,
and Structural Approaches section of the journal, Asada,
Hughes, and Chriqui (“Insights on the Intersection of Health
Equity and School Nutrition Policy Implementation: An
Exploratory Qualitative Secondary Analysis”) describe how
secondary analyses of existing data can be used to further
explore a concept noticed in an original study, but tangential
to the original research questions. The authors recoded data
from a multiple case study and key informant interviews in
three related studies to explore mechanisms through which
universal school nutrition reform may exacerbate health dis-
parities. Stakeholder insights revealed how the complex
interplay between home and school environments intersected
with socioeconomic challenges.
Separate articles by Dill and Sarah Hernandez and col-
leagues used in-depth individual interviews to identify cul-
tural and social strengths within marginalized populations.
Dill uses ethnographic individual interviews to describe how
spirituality and religiosity foster resilience among African
American youth in East Oakland, CA (“‘Wearing My
Spiritual Jacket’: The Role of Spirituality as a Coping
Mechanism Among African American Youth”). Her study
illuminates how spiritual development facilitates healthy
behavior among young people and how this cultural strength
can be the foundation of interventions to improve the health
of African American youth. Sarah Hernandez and colleagues
describe the value of supplementing traditional community
assessment methods with oral histories. In “Oral Histories as
a Critical Qualitative Inquiry in Community Health
Assessment,” the authors describe a collaboration with
StoryCorp to collect 32 oral histories from residents of a
Chicago neighborhood. The method, and the use of listening
sessions rather than a traditional thematic analysis, led to
holistic understandings of health and a counternarrative to
deficit-oriented community assessments. These articles dem-
onstrate how within-group approaches can illuminate
strengths and assets of populations and communities that
otherwise may be missed in comparative studies
(Airhihenbuwa, 1995; Bediako & Griffith, 2007).
In four additional articles that feature analyses of in-depth
individual interviews, authors show how analyses of data
from individual interviews can provide insight into social
determinants of health that are critical to consider in develop-
ing and implementing policy and programmatic interven-
tions. In “Qualitative Research Methods to Advance Research
on Health Inequities Among Previously Incarcerated Women
Living With HIV in Alabama,” Sprague, Scanlon, and
Pantalone describe the use of life course or life history narra-
tives to explore how adverse events in childhood and young
adulthood are related to HIV and incarceration and how this
approach can help “untangle the web” of influences that

Griffith et al. 675
contribute to disparities in each separately and how their
effects can exacerbate one another over time. In their paper,
the authors present a life history chart for one participant and
also discuss how they employed intersubjective dialogue in
the study. In the second article, “‘She Gave Me the Confidence
to Open Up’: Bridging Communication by Promotoras in a
Childhood Obesity Intervention for Latino Families,” Falbe
and colleagues report on in-depth, semistructured interviews
they conducted with providers and parents who participated
in the Active and Healthy Families program (an effective, cul-
turally tailored, family-based program for addressing child-
hood obesity disparities among predominately immigrant
Latinos using a physician, dietician, and promotora). Applying
a grounded theory analysis, the researchers used qualitative
methods to inform the development of a conceptual model
highlighting the unique processes through which promotoras
enhance the impact of team-based, primary care programs
and can bridge important cultural divides with immigrant
Latino communities. The third article in this section by
Hopfer and colleagues (“A Narrative Engagement Framework
to Understand HPV Vaccination Among Latina and
Vietnamese Women in a Planned Parenthood Setting”), the
authors apply narrative communication theory to examine
how these women ascribe meaning to their lived experiences,
decisions, and conversations about HPV (human papilloma-
virus) vaccination. The authors assert that identifying cultur-
ally authentic and relatable vaccine decision narratives is
critical in effectively engaging Vietnamese and Latina women
in HPV vaccination, and will use the findings to inform the
adaptation and content of an evidence-based HPV vaccine
intervention. In the final article in this section, Diana
Hernández and colleagues use ethnographic observations and
in-depth interviews to examine sociostructural and individual
factors that influenced HIV/HCV (hepatitis C virus) risk in
people who use drugs in Puerto Rico (“When ‘the Cure’ Is the
Risk: Understanding How Substance Use Affects HIV and
HCV in a Layered Risk Environment in San Juan, Puerto
Rico”). In this study, researchers accompanied a community
partner in visiting shooting galleries and attended overnight
outreach activities that allowed them to observe social venues
typically not accessible to outsiders. In addition to highlight-
ing the value of deeper engagement in a community (i.e.,
more than a one-time interview with study participants), the
resulting ethnography brings to life the complex interplay of
sociostructural factors in perpetuating risk behaviors and lim-
iting use of treatment services.
In addition to the use of in-depth individual interviews,
one of the signature approaches to providing insight into
community context and people’s daily experiences is photo-
voice. Barrington and colleagues (“Using Photo-Elicitation
Methods to Understand Resilience Among Ultra-Poor Youth
and Their Caregivers in Malawi”) apply a photo-elicitation
method to examine the local context and meanings of resil-
ience among youth–caregiver dyads who were beneficiaries
of a cash transfer program to improve health in Malawi. In
“Voices and Views of Congolese Refugee Women: A
Qualitative Exploration to Inform Health Promotion and
Reduce Inequities,” McMorrow and colleagues describe a
community-based participatory research study grounded in
anthropology. The authors use photovoice and semistruc-
tured interviews to provide in-depth understanding of the
experiences and sociocultural context of health and health
care for Congolese refugee women in Indianapolis, Indiana.
The research highlights how photo-elicitation and photo-
voice have important utility for informing culturally tailored
health education and understanding existing assets for pro-
moting health among this population. In addition, the work
provides an example of the promise of community-based
participatory research using a qualitative approach to pro-
vide insights into promoting health equity.
In the final section, contributors to the special issue use
focus groups as formative research to identify pragmatic and
concrete factors that may hinder or facilitate future interven-
tions and health communication strategies. James and col-
leagues (“‘You Have to Approach Us Right’: A Qualitative
Framework Analysis for Recruiting African Americans Into
mHealth Research”) use triad focus groups to explore strate-
gies to recruit African American adults into mobile health
research studies. Floyd and colleagues used a community-
based participatory research approach and focus groups to
examine the interest in and appropriateness of a beauty salon–
based intervention to promote colorectal cancer screening
among African American women (“Acceptability of a Salon-
Based Intervention to Promote Colonoscopy Screening
Among African American Women”). In an article by
McLaurin-Jones and colleagues (“Using Qualitative Methods
to Understand Perceptions of Risk and Condom Use in
African American College Women: Implications for Sexual
Health Promotion”), the authors conducted thirteen focus
groups and used a phenomenological qualitative approach
with 100 young adult African American women to provide
in-depth insight into why condom use remains low among
this population. The goal of their study was to inform more
nuanced messaging in sexual health promotion programs.
The issue concludes with a commentary by Shelton,
Griffith, and Kegler (2017) that explores the role of qualita-
tive research in informing theory that underlies programmatic
and policy approaches to pursue health equity. In addition to
highlighting the critical role that theory plays in the field of
health behavior, this article offers insight into the critical role
that qualitative research can and hopefully will play in future
efforts to advance the nation’s efforts to achieve health equity.
For example, ecological models have been an important foun-
dation of health behavior and health disparities research, but
the misconception that biological and behavioral factors are
more proximal to health and that social factors are more distal
have led to the misconception that the former exerts more
influence on health and health disparities than the latter
(Krieger, 2008). Shelton and colleagues reiterate that while
there is much that can be learned from other fields, health

676 Health Education & Behavior 44(5)
behavior as a field has a lot to contribute to informing, evalu-
ating, and refining theory in efforts to address health equity.
This editoral nor this issue is an effort to assert that qualita-
tive methods are somehow superior to quantitative ones. The
goal is rather to illustrate how qualitative research is an
increasingly important methodologic tool in our efforts to
understand and inform health equity. The 15 articles that
comprise this special issue, taken together, illustrate the
diverse ways that qualitative research enrich our understand-
ing of the determinants of health that inform health equity
research. Thus, several concluding points are warranted.
First, the methods discussed in this special issue do not
primarily seek to quantify answers to research questions;
their strength is in emphasizing the meanings, experiences,
and views of participants in the context of their lives and set-
tings (Pope & Mays, 1995). Focusing on questions of “how”
and “why” rather than “how many” is an important aspect of
efforts to understand the life course, social, cultural, and his-
torical context of health and health behavior. Qualitative
methods can document and provide insight into aspects of
complex behaviors, attitudes, and interactions that quantita-
tive methods cannot.
Second, a key strength of qualitative research is its ability
to consider and incorporate contextual information that is
difficult to capture and incorporate in quantitative research;
these contextual factors can be essential in informing the
interpretation and dissemination of findings. Qualitative
research is well suited to capture the multiple realities and
truths in the subjective experiences of participants (Wright,
Wahoush, Ballantyne, Gabel, & Jack, 2016). As a result,
qualitative methods are extremely useful for examining the
explicit and implicit theories that underlie established theo-
ries and that explain why disparities exist and what can be
done to reduce or eliminate them.
Finally, qualitative research is uniquely positioned to
identify and focus on the factors that are of the greatest inter-
est to the people whose health we seek to improve through
our programs and policies (Syme, 2008); it holds a unique
place in helping researchers elucidate the root causes of
health disparities and identify the mechanisms and pathways
toward health equity. For these reasons, we hope this special
issue catalyzes a conversation and renewed interest in train-
ing researchers and practitioners in qualitative research as a
key tool with which to promote health equity.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
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