Qualitative research methods within the addictions

Abstract

In 1998, Fountain & Griffiths conducted a content analysis on papers published during 1995–96 in three leading international drug publications: Addiction, Drug and Alcohol Review and Addiction Research (Fountain & Griffiths 1998). Of the 291 papers scrutinized, only 17 (6%) reported on studies that had wholly or partially used qualitative methods. In Addiction, the proportion (at 2%) was even lower. Addiction published just three qualitative papers in 2004: Amos et al. (2004); Furst et al. (2004); and Rhodes, Davis & Judd (2004). Such marginality prompts uncomfortable questions. Is qualitative addiction research only a minority interest? Are qualitative analyses somehow less informative or less valuable than quantitative investigations? Or do some addiction journals directly or indirectly militate against the publication of qualitative research? It was with interest, then, that we received an invitation to write a review of qualitative methods for Addiction. Our brief was to produce a statement that would explain what qualitative research is, highlight its strengths and weaknesses, and outline some of the important principles and processes involved in its undertaking. The offer provided reassuring evidence that Addiction does welcome qualitative work and recognizes its importance. In responding to our task, we hope that we have written a paper that will especially interest and assist newcomers to the qualitative field. For others, our intention is not to offend by reporting what may sometimes seem obvious. The aim is rather to offer a reminder that we need to see a high standard of qualitative work appearing more often in journals such as Addiction. Qualitative research has been the historical bedrock of a number of social science disciplines, such as anthropology and history. However, interest in the approach has grown in recent decades as more researchers in basic disciplines and applied fields have adopted a qualitative paradigm (Miles & Huberman 1994, p. 1). Within the addictions, qualitative studies have been occurring regularly since the 1920s. In fact, Feldman & Aldrich (1990) suggest that Herodotus' fifth-century account of marijuana use in Scythian purification rites is a very early example of a qualitative ethnography. Over the years, qualitative methods have provided drug researchers with valuable techniques of scientific inquiry. In return, drug taking has provided qualitative investigators with an ideal arena in which to apply and develop their methods (Fountain & Griffiths 1998). Although defining qualitative research is not straightforward (see, for example: Denzin & Lincoln 1994; Lambert, Ashery & Needle 1995), it is generally accepted that qualitative researchers study phenomena in their natural settings and their aim is to understand how people account for, take action and otherwise manage their day-to-day situations (Miles & Huberman 1994). As Rhodes (2000) has argued, qualitative addiction research seeks both to describe the social meanings that participants attach to drug use and the social processes by which such meanings are created, reinforced and reproduced. In particular, qualitative research focuses on exploring the details of people's lived experiences and on appreciating why drug-using behaviours occur and how they are understood in different contexts among different social groups (Rhodes 1995). Frequently, qualitative research and quantitative research are described in oppositional terms (Martin & Stenner 2004). Qualitative work is perceived as falling within a 'realist' tradition, utilizing data that are 'deep' and 'rich' to explore 'subjective understandings' and 'values'. In contrast, quantitative work is associated with a more 'positivist' epistemology, employing 'hard data' to focus on 'objectivity' and 'fact' (ibid.). Important differences between the two methods are evident. For example, qualitative studies are typically less structured than quantitative ones and tend to take more time to complete. They generally yield much larger volumes of data from a smaller number of individuals. Additionally, analysis is more explicitly interpretive, creative and personal (Walker 1985). Despite this, qualitative and quantitative studies can usefully be undertaken together and it is therefore better to see them as complementary rather than adversarial approaches (McKeganey 1995). For example, qualitative work can be performed as a preliminary to quantitative research. This might involve using qualitative techniques to provide background information on issues and concepts to be investigated in a subsequent survey. Qualitative methods can also supplement quantitative work. Here, qualitative data might be used either to validate findings from a quantitative study ('triangulation') or to help build a wider picture of a particular phenomenon under investigation. Thirdly, qualitative research can complement quantitative work, for example by exploring complex phenomena or areas not amenable to quantitative inquiry (Pope & Mays 1995). In practice, qualitative research is an umbrella term that is used to describe a variety of methodological approaches. Space does not permit an exhaustive account of what might be involved, but a brief review of some of the main qualitative techniques and sources of data that have been employed by drug and alcohol researchers in recent years will illustrate some of the diversity of the qualitative paradigm. Ethnography has played a particularly important role in qualitative addiction research. The ethnographer seeks to describe the lives of a group of people in a way that is faithful to how they see it themselves (McNeill 1990, p. 64). The intention is to understand the underlying patterns of behaviour and meanings of a culture—including the tacit rules, symbols and rituals that guide group norms (Geertz 1973; Agar 1986, 1996). Ethnographers depend heavily on observation and, in some cases, complete or partial integration into the society being studied. They also often conduct in-depth interviews with community members and examine materials or artefacts that are relevant to people's everyday lives. In the field of alcohol research, there is a very long tradition of ethnographic studies that have mostly been conducted by anthropologists working in remote regions of the world (SIRC 1998). For example, Lemert examined the relationship between drinking, alienation and cultural change among North-west coast Native Americans in the 1950s (Lemert 1958). More recently, Eber (2000) explored female identities, roles, relationships and sources of power in the context of women and drinking in a Mexican community. Ethnographies of illicit drug use have predominantly been conducted in the United States and one of the most often-quoted is a study of marijuana users by the sociologist, Howard Becker (1953). Becker showed how social setting or context is a significant determinant in how individuals become marijuana users, as well as why they continue or desist from its use. Other qualitative techniques (such as themed interviews, focus groups and open-ended questions inserted into quantitative surveys) are conducted during one-off contact with research subjects and have the advantage of being less time-consuming and cheaper to conduct than a full ethnographic study. Equally, their flexibility enables them to generate good-quality data on a wide range of issues from a wide range of individuals. For example, Nygaard et al. (2003) interviewed young people who had been involved in drink driving episodes about their experiences of drink driving and riding with drink drivers. Beich, Gannik & Malterud (2002) interviewed general practitioners to explore the suitability of a screening-based intervention for excessive alcohol use, and Lawrie et al. (2003) interviewed pharmacy customers to ascertain their views and experiences of using pharmacies that provided needle exchange services. A further qualitative technique that builds upon the interview approach and has been used by addiction researchers is narrative research. Here, those being studied are encouraged to tell their stories and these are then analysed in terms of their form (e.g. structure of the plot) and content (e.g. what happened). For example, Hilte (2000) analysed women's recovery from psychoactive substance abuse by examining the main characters in their accounts and by exploring how characters' actions impacted on subsequent events. Not dissimilarly, McKeganey et al. (1995) and Hughes (1998) have used personal stories but combined them with projective techniques in the form of vignettes and extended vignettes. These involve presenting study participants with a character and setting and asking them for responses to particular events or moral dilemmas. Further to the above, qualitative investigators have used both community engagement and action research to give those being studied a participatory role in the research process. In these approaches, local people may help to design the study, assist in conducting the research and contribute to feeding the results back into local action. Both qualitative and quantitative components can be involved. For example, local black and minority ethnic community organizations across England have been involved recently in undertaking their own needs assessment projects relating to drug prevention, education and treatment issues (Winters & Patel 2003). In Scotland, meanwhile, a study of community responses to drug use in rural Lanarkshire resulted in local people initiating a breakfast club and homework club for children living in an area badly affected by illegal drug use and problem drinking (Parkin et al. 2001). Lastly, rapid assessment methods provide a good example of qualitative and quantitative approaches being used together. Rapid assessment methods have been developed to exploit diverse data sources and produce quick, practically orientatated assessments in areas where epidemiological systems are poor (Vingoe 2000). The first rapid assessments occurred during the United Nations Drug Control Programme missions to Vietnam and Lebanon (Ingold 1994; Power 1996). More recently, Fitch et al. (2003) have conducted a rapid assessment of drug and alcohol use in Jersey. This study involved analysis of existing data sources, key stakeholder interviews/focus groups, a community-recruited survey and prevalence estimation of problem drug users. Its aim was to inform the development of strategy performance indicators and to make recommendations for change in existing prevention, law enforcement and surveillance activities. From the above, it is clear that qualitative techniques involve collecting and analysing one or more types of data. Moreover, just as qualitative and quantitative methods can profitably be used together, so two or more qualitative techniques and data sources can be used within one study to complement, supplement and validate each other. The main types of qualitative data are observations, interviews and documentary materials. A useful summary of some of the respective advantages and disadvantages of each of these is provided by Creswell (2003, pp. 186–187). Observations can be gathered in various ways. For example, researchers may engage in roles varying from a non-participant to a complete participant. Equally, they may take fieldnotes on the behaviour and activities of individuals in an unstructured or semistructured way. These notes can then be kept in the form of a diary, an unfolding narrative or even personal letters. Bourgois' direct observations of the lived experiences of homeless heroin users in San Francisco provide an important example of the power and value of this type of material (Bourgois 1998a,b). Interview data are usually collected in person or sometimes by telephone. The interview format may be structured, semistructured or unstructured and can involve one interviewer and one respondent (one-to-one interviewing) or be conducted in small groups (focus groups). Because the researcher cannot be expected to remember all the responses given to their questions, interviews are generally audio-recorded and transcribed verbatim. It is the interview transcripts that are later analysed, increasingly with the assistance of computer software packages. Neale (2002) provides a detailed account of analysing semistructured interview data from a study of non-fatal drug overdose using the computer program WinmaxPro. Documentary materials can include newspaper articles, books, reports, casenotes and audio-visual and digital media. Cooper (2004) analysed 297 medical articles on opiate addiction in order to explore the relationship between US health professionals' theories of opiate addiction's aetiology and contemporaneous perceptions of opiate addicts' race/ethnicity, social class and gender. Gilman (1998) used Usenet news groups on the internet to gather information about routes into heroin addiction, and Taylor et al. (2004) analysed video data produced by filming drug injectors in their homes and other venues to explore how injecting practices place individuals at risk of HCV infection and the implications of this for harm reduction. Having introduced something of the nature and diversity of qualitative research, it seems important to review why it might be used. Fundamentally, it has been argued that quantitative methods are too narrow and too reductionist for studying the social world (Martin & Stenner 2004). Human beings are purposeful, goal-seeking, feeling, meaning-attributing and meaning-responding creatures (Hughes 1976, p. 24). Consequently, it is necessary to understand how they perceive and interpret their environment if their behaviour is ever to be interpreted usefully. Qualitative investigations facilitate this by enabling the researcher to understand drinking and drug use from participants' perspectives. Because of their capacity to explore and explain human behaviour, qualitative methods have proved very valuable in demystifying drug and alcohol use and replacing stereotypes and myths about addiction with more accurate information that reflects the daily reality of substance users' lives. In so doing, ethnographic research has humanized the image of the drug taker and drinker, improved general understanding of the everyday context of drug use and drinking, and facilitated the development of socio-cultural perspectives on substance consumption. This has resulted ultimately in important new theory, policy and practice. Thus, ethnographic research conducted during the 1950s and 1960s questioned the prevailing medical assumption that drug addiction was a disease and drug users were passive, anxious and inadequate people. Instead, it showed that drug addiction was a social experience that needed to be understood and that drug users were normal self-determining individuals who were participating in a life-style that just happened to be deviant (Faupel 1991; Stephens 1991). Similarly, anthropologists have questioned the high level of alcohol problems associated commonly with tribal and village cultures, arguing that while drunkenness may be common, alcohol addiction is actually rare (Leland 1976; Heath 1982). Furthermore, the preoccupation with problem drinking detracts from its more pleasurable and routinized aspects (Levine 1981). In terms of formulating new policy and practice, qualitative methods were employed in the 1990s in response to the public health imperative to reduce HIV and other blood-borne infections linked to injecting drug use. This was in recognition of the fact that effective interventions needed to be based on an understanding of the complex risk behaviours and social factors involved in drug taking (Leshner 1998). Accordingly, various qualitative techniques were used to examine injecting practices and especially the social and cultural dimensions of needle sharing (cf. McKeganey & Barnard 1992; Grund 1993). The rich data resulting from this work were then used to inform the expansion of crucial harm reduction services. Qualitative research has also been making contributions to the expanding literature on drug treatment and its effectiveness by exploring users' views and experiences of service provision. Here, the use of qualitative methods is underpinned by the belief that treatment is most likely to be effective when individuals feel positive about and satisfied with the support that they receive. For example, Neale (1998) investigated drug users' opinions of drug workers and other service providers while Copeland (1997) examined the barriers drug users face when attempting to access help. In the alcohol field, Thom et al. (1992) used open questions and free discussion to generate qualitative material on patients' perceptions and experiences of clinic and general practice-based care for drinking problems. Meanwhile, Lock (2004) conducted focus groups to explore patients' views and experiences of alcohol and brief intervention in primary health care. Further to the above, qualitative studies have always been invaluable in accessing 'hidden' or 'hard-to-reach' populations. The illegality of much drug-related activity, users' erratic life-styles and/or the social stigma associated with substance misuse mean that addiction research often concerns hidden populations (Power 1995). Qualitative techniques (such as interviewing or observing venues where drugs are sold, bought and consumed) increase the addiction researcher's knowledge of hidden and hard-to-reach groups. Equally, feelings of trust and rapport emerging during fieldwork can enable qualitative researchers to permeate the complex social networks that link substance users and their associates together. In addition, qualitative researchers have developed innovative sampling techniques to minimize the potential for bias in their data. For example, snowball sampling is a carefully staged process that involves the recruitment of new respondents through referrals from earlier respondents (see Kemmesies (2000) for a full description). As indicated previously, qualitative research is also important in identifying emerging trends in drug taking. According to Clatts et al. (2002), institutionally derived sources of data used to forecast changes in patterns of drug abuse typically omit a number of hidden populations. In contrast, ethnographic research can identify and track new and hidden drug-using groups as well as new and hidden drug-taking practices. One reason for this is that qualitative researchers are encouraged to go where the data lead them (Belgrave, Zablotsky & Guadagno 2002). Furthermore, qualitative data can preserve the of social so to identify which events lead to which (Miles & Huberman 1994). Addiction researchers in recent years, this by using qualitative methods to explore both the increase in drug prevalence among young people as well as the this (Fountain & Griffiths 1998). qualitative techniques are effective in and/or illegal substance use and misuse in but particularly very drug-related evidence of this, qualitative researchers have regularly personal information on drug and other drug-related behaviour, injecting while or and feelings of trust and rapport between the researcher and research participants facilitate about Similarly, qualitative to the social and cultural of their study can an and that those being to their 2002). the strengths of qualitative work, there are As & Stenner (2004) qualitative techniques at the of the scientific of and In other more sampling techniques and the small of individuals participating in qualitative work mean that findings can be as of drug users in and are in order to a and more understanding of lives and this of is an for those to a qualitative other issues can One problem is the of about what qualitative research is, by the variety of with its own rules, and can be adopted The of and in of data that qualitative researchers do not only need to

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