Qualitative Research Methods in Chronic Disease: Introduction and Opportunities to Promote Health Equity

Reimagining Rural Health Equity: Understanding Disparities And Orienting Policy, Practice, And Research In Rural America

A narrative has taken hold that public health has failed the US. We argue instead that the US has chronically failed public health, and nowhere have these failures been more apparent than in rural regions. Decades of underinvestment in rural communities, health care, and public health institutions left rural America uniquely vulnerable to the COVID-19 pandemic. Rural communities outpaced urban ones in deaths, and many rural institutions and communities sustained significant impacts. At the same time, the pandemic prompted creative actions to meet urgent health and social needs, and it illuminated opportunities to address long-standing rural challenges. This article draws on our cross-disciplinary expertise in public health and medical anthropology, as well as our research on COVID-19 and rural health equity in northern New England. In this Commentary, we articulate five principles to inform research, practice, and policy efforts in rural America. We contend that advancing rural health equity beyond the pandemic requires understanding the forces that generate rural disparities and designing policies and practices that account for rural disadvantage.

Determinants of physical activity promotion in primary care from the patient perspective of people at risk of or living with chronic disease: a COM-B analysis

BACKGROUND

Chronic disease (CD) accounts for more than half of the overall global disease burden and physical activity (PA) is an established evidence-based strategy for the prevention and management of CD. Global policy emphasises the value of embedding PA into primary healthcare, highlighting the positive effects on PA behaviour. However, there is limited implementation of PA protocols in primary care, and research is needed to guide its integration into routine practice. The voice of the patient is underrepresented in the literature, resulting in the absence of critical insights into determinants of PA promotion in primary care. The purpose of the research was to identify the perspectives of people at risk of or living with CD on the determinants of PA promotion in primary care and to map these determinants across the six COM-B constructs.

METHODS

Semi-structured interviews (n = 22), guided by the COM-B model were conducted with people aged 35-60 years, at risk of or living with CD and not meeting the PA guidelines. A hybrid analytic approach of thematic inductive and deductive analysis was applied to the participant transcripts guided by a COM-B informed coding framework.

RESULTS

In total, 37 determinants across constructs related to capability, opportunity and motivation were prominent, examples include; physical capability constraints, the conflation of exercise with weight management, credibility of the health services in PA advice, communication styles in PA promotion, expectations of tailored support for PA, social support, accessibility, and integration of PA into routine habits.

CONCLUSION

Exploring the determinants of PA promotion through the lens of the COM-B model facilitated a systematic approach to understanding the primary care user perspective of the healthcare professional (HCP) broaching the topic of PA. Findings emphasise the value of HCPs being supported to broach the issue of PA in a therapeutic and patient-centred manner using diverse and flexible approaches, while highlighting the importance of tailored, accessible PA opportunities that build self-efficacy and foster social support. The research provides valuable learnings to support PA promotion and the development of strategies in primary care through encompassing the perspective of those living with or at risk of CD.

Enduring Effects of the COVID-19 Pandemic on Food Access, Nutrition, and Well-Being in Rural Appalachia

The COVID-19 pandemic produced acute effects on health inequities, yet more enduring impacts in vulnerable populations in rural Appalachia are understudied. This qualitative study included three focus groups with thirty-nine adults (74% female, mean age 52.7 years) to obtain perspectives on the impact of the COVID-19 pandemic on well-being in Martin County, Kentucky, in fall 2022. Grounded Theory was employed using an iterative inductive-deductive approach to capture the lasting effects of the COVID-19 pandemic on health practices and status. Three prominent themes emerged: (1) increased social isolation; (2) household cost of living strains caused by inflation; and (3) higher food prices and diminished food availability causing shifts in food purchasing and consumption. Participants noted that the rising cost of living resulted in residents having to "choose between medication, food and utilities". Increased food prices resulted in residents "stretching" their food, modifying how they grocery shopped, and limiting meat consumption. Persistent food shortages were exacerbated by there being few grocery stores in the county. Lastly, increased social isolation was profoundly articulated as widely impacting mental health, especially among youth. Our findings underscore the ongoing deleterious effects of inflation and food supply chain disruptions in this rural, geographically isolated community, which resulted in difficult spending choices for residents.

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Living and Coping with Olfactory and Taste Disorders: A Qualitative Study of People with Long-COVID-19

Taste and smell disorders are common symptoms of SARS-CoV-2 acute infection. In post-COVID-19 condition, symptoms can persist leading to disruption in patients' lives, to changes in their coping skills, and to the need to develop strategies for everyday life. This study aimed to describe the perspective of a group of patients with Long-COVID-19, a condition where loss of taste and/or smell was the most predominant symptom. A qualitative descriptive study was conducted. Participants who had suffered SARS-CoV-2 infection and had Long-COVID-19 loss of taste and/or smell were recruited. Purposive sampling was applied, and participants were recruited until data redundancy was reached. In-depth interviews were used for data collection and thematic analysis was applied. Twelve COVID-19 survivors (75% women) were recruited. The mean age of the participants was 55 years, and the mean duration of post-COVID-19 symptoms was 25 months. Three themes were identified: (a) Living with taste and smell disorders, describing the disorders they experience on a daily basis, how their life has changed and the accompanying emotions, (b) Changes and challenges resulting from the loss of taste and smell, changes in habits, self-care and risk in certain jobs or daily activities, (c) Coping with taste and smell disorders, describing the daily strategies used and the health care received. In conclusion, Long-COVID-19 taste and/or smell disorders limit daily life and involve changes in habits, meal preparation, and the ability to detect potentially dangerous situations.

Methodologies to Advance Health Equity and Reduce Health Inequities in Nursing Research

The Centers for Disease Control and Prevention affirm that health equity is only achieved when everyone has opportunities to attain full health potential without disadvantages related to social position or socially determined circumstances. To reduce health inequities in nursing research, researchers must increase diversity in study samples and ensure that study participants are representative of all populations in the United States. Identifying effective methods for recruiting underrepresented populations must be a thoughtful and reflective component of every research methodology. To achieve health equity in research studies, nurse researchers and clinicians must carefully plan ways to recruit study participants who represent all populations.

Community Engagement in Behavioral Medicine: A Scoping Review

BACKGROUND

Behavioral medicine has made key contributions toward improving health outcomes. Engaging community partners in research is critical to addressing persistent health inequities. The aim of this scoping review was to explore how researchers engaged community partners within the field of behavioral medicine research from 2005 to 2023.

METHOD

Publication databases and gray literature were searched for research that engaged community partners to address questions relevant to behavioral medicine. Articles were screened by title and abstract, and then by full text. Articles meeting the inclusion criteria were coded using the framework provided by the Engagement Navigator to identify engagement approaches, methods, and tools and when they were used during the research.

RESULTS

Of 1486 articles initially identified, 58 met the inclusion criteria. Most articles used well-known approaches (e.g., community-based participatory research; 67%), methods (e.g., advisory committees; 59%), and tools (e.g., interviews; 41%), and engaged with healthcare service providers (62%) and/or patients (53%). Community partners were most often included in research planning and design (79%), and less often in dissemination (45%).

CONCLUSION

Community engagement has considerable potential to address health inequities. Our assessment of the approaches, methods, and tools used by behavioral medicine researchers to engage with a diverse range of community partners points toward promising strategies for enhancing the impact of community engagement. Researchers should incorporate explicit descriptions of community engagement strategies in publications, an outcome that could be facilitated by clear publishing guidelines, structured reporting tools, and clear messaging from funders about the value of community engagement in behavioral medicine research.

Cultural Beliefs and Practices in Self-Management of Diabetes Among Pnar Women in Meghalaya, India

PURPOSE

The purpose of the study was to explore the cultural beliefs and practices of the Pnar tribe in terms of their self-management of diabetes.

METHODS

A qualitative study design using an ethnographic approach was adopted to understand the experiences of the Pnar women with type 2 diabetes. Around 60 women living with diabetes across 20 villages in the Thadlaskein rural block were interviewed in the Pnar language. Thematic analysis was employed to identify the pattern related to beliefs and cultural practices in the self-management of diabetes across the data set.

RESULTS

Misconceptions related to diet, such as all vegetables grown underground need to be avoided and bitter herbs and vegetables are good for blood glucose control, were reported. Participants used home remedies and complementary and alternative medicine to bring down their blood glucose levels. Participants believe that diabetes is an episodic or short-term illness and can be cured through herbal medicine. Participants reported that consuming atta or round flat bread made of wheat flour instead of rice caused "acidity."

CONCLUSIONS

Misconceptions are barriers to disease management, which are often shaped in people's minds by culture. Therefore, health care service providers must know what people think about diabetes and its management. Accordingly, information related to diabetes should be disseminated to the masses for effective management of diabetes.

Similar skills, different frames: a thematic analysis exploring conceptualizations held by community-based organization practitioners and academics regarding skills to use evidence-based interventions to address cancer inequities

BACKGROUND

Community-based organizations (CBOs) are critical partners in delivering evidence-based interventions (EBIs) to address cancer inequities. However, CBO practitioners do not typically have access to opportunities to build the necessary capacity (skills, knowledge, motivation, and resources) for using EBIs. Although capacity-building interventions can offer a solution, inconsistent definitions and measurements of capacity limit the ability to develop and evaluate such efforts. We explored how and why conceptualizations of core skills for EBI use differ between practitioners and academics addressing cancer and other health inequities. We anchored the inquiry with a commonly used set of target skills for EBI capacity-building efforts.

METHODS

The study was conducted by an interdisciplinary team of academic researchers and CBO practitioners. We gathered data through semi-structured, hour-long interviews with practitioners and academics working to address cancer and other health inequities (n = 19). After hearing a brief vignette about a CBO addressing cervical cancer inequities, participants considered a widely accepted list of skills for EBI use that included assessing needs, engaging stakeholders, and selecting, adapting, implementing, evaluating, and sustaining the EBI. We used a team-based, reflexive thematic analysis approach grounded in critical and constructivist perspectives.

RESULTS

Overall, the original list resonated with practitioners and academics and they added new skills to the list (cultural humility and systems change). Practitioners' responses described skills from the reference point of addressing broader community needs and context and achieving change over the long term, emphasizing aspects of health promotion in their descriptions. Academics offered a mix of perspectives, with some focused on addressing community needs (and related flexibility regarding EBIs) but more emphasized skills needed to deliver a specific EBI to achieve a focused set of health and equity outcomes.

CONCLUSIONS

There is a significant opportunity to leverage complementary expertise and perspectives held by practitioners and academics addressing cancer inequities. However, the different frames utilized suggest proactive efforts will be required to find alignment across groups, particularly in valuing diverse contributions and identifying relevant outcomes of interest for each group. Such alignment is critical to designing effective capacity-building interventions and supporting the routine utilization of EBIs to address cancer inequities.

Understanding illness experiences of patients with primary sclerosing cholangitis: a qualitative analysis within the SOMA.LIV study

BACKGROUND

Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease with a largely unpredictable course. Due to limited treatment options, individuals may for many years suffer from distressing symptoms and the emotional burden of an uncertain future. The need to shift from cure to care of PSC has spurred an interest into patients' health-related quality of life. Qualitative research in this context remains scarce. Hence, this study aimed to enrich the clinical understanding about the lived experience of PSC through a qualitative approach.

METHODS

A total of 20 patients with PSC were recruited at a specialist centre for autoimmune liver disease in Germany and engaged in semi-structured telephone-based interviews between March and June 2022. Verbatim transcripts were interpreted using inductive thematic analysis.

RESULTS

An overarching concept of 'a wave-like experience' was formulated to illustrate the dual and shifting nature of living with PSC. Reflecting upon this central idea, three major themes were generated to address important aspects of participants' illness experiences: 'Invisible presence' focused on perceptions of suffering from a seemingly hidden illness that periodically reveals itself through specific trigger events. 'Embracing the threat' captured the psycho-emotional response shift to this chronic disease from a predominantly negative to a coping-oriented pattern with regular setbacks. 'Between control and constraints' uncovered restrictions that PSC enforces onto patients' lives and their desire for controllability.

CONCLUSIONS

The present study provides an in-depth look at the fluctuating tensions arising from a life with PSC. Insights on perceived invisibility, disease-related triggers of emotional distress and the complexity behind self-management highlight opportunities for enhanced clinical support of this patient group.

Applying Rapid Qualitative Analysis for Health Equity: Lessons Learned Using "EARS" With Latino Communities

Qualitative research amplifies the voices of marginalized communities and thus plays a critical role in shaping our understanding of health inequities and their social determinants. Traditional qualitative approaches, such as grounded theory or thematic analysis, require extensive training and are time- and labor-intensive; as such, they may not be adequately suited to address healthy equity issues that require a swift response. Rapid qualitative analysis (RQA) is an action-oriented approach to qualitative data analysis that may be used when findings are needed to quickly inform practice. RQA capitalizes on using a team to summarize key points from qualitative data into matrices to explore relevant themes efficiently and systematically. In this paper, we provide case examples from our work applying RQA to health equity research with Latino communities to address community needs, such as responses to public health emergencies and the development of service delivery and technology interventions for infectious and chronic diseases. We draw from our collective experiences to share lessons learned and provide the following specific recommendations ("EARS") to researchers interested in applying RQA for health equity research: (1) Employ RQA to address rapidly evolving, urgent, health equity challenges; (2) Assure quality and rigor throughout the RQA process; (3) Respond to barriers and problem-solve as needed; and (4) Strengthen community relationships before, during, and after using RQA. Overall, we advocate for the use of RQA to promote health equity due to its ability to integrate the vital perspectives of marginalized communities and efficiently respond to their needs.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

Practical Strategies for Health Equity Researchers to Enhance Analytic Rigor and Generate Meaningful Insights From Qualitative Data

Researchers and public health practitioners increasingly need to leverage diverse methodologic approaches in health equity research that will lead to innovations in the assessment of health inequities and development of interventions to decrease health inequities. One well-suited approach is the use of robust qualitative methods (alone or in combination with quantitative methods). As more health equity researchers employ qualitative methods in their study designs, additional guidance is needed on how to conduct robust and rigorous qualitative data analyses. We share a 4-step analytic strategy for health equity researchers and practitioners - particularly those with limited training in qualitative data analysis - that can be used to effectively execute qualitative analysis to inform health equity-driven efforts. These strategies will guide those less experienced in qualitative methodology to employ a pragmatic approach to analysis that is sound, reasonable, and produces meaningful insight that can be used to inform efforts to advance health equity for communities with the greatest needs.

Opportunities to Improve Long COVID Care: Implications from Semi-structured Interviews with Black Patients

BACKGROUND

Long coronavirus disease (COVID) is an emerging condition that could considerably burden healthcare systems. Prior qualitative studies characterize the experience of having long COVID, which is valuable for informing care strategies. However, evidence comes from predominantly White samples. This is a concern because underrepresentation of Black patients in research and intervention development contribute to racial inequities.

OBJECTIVE

To facilitate racial equity in long COVID care, the purpose of this qualitative study was to inform the development of care strategies that are responsive to the experiences and perspectives of Black patients with long COVID in the United States of America.

METHODS

Using convenience sampling, we conducted race-concordant, semi-structured, and open-ended interviews with Black adults (80% female, mean age = 39) who had long COVID. We transcribed and anonymized the recorded interviews. We analyzed the transcripts using inductive, thematic analysis. Theme development focused on who can help or hinder strategies for reducing health inequities, what should be done to change care policies or treatment strategies, and when are the critical timepoints for intervention.

RESULTS

We developed four main themes. Participants reported challenges before and after COVID testing. Many participants contacted primary care physicians as a first step for long COVID treatment. However, not all respondents had positive experiences and at times felt dismissed. Without a qualifying diagnosis, participants could not obtain disability benefits, which negatively influenced their employment and increased financial hardship.

CONCLUSIONS

There are possible targets for improving long COVID care, from COVID testing through to long-term treatment plans. There is a need to increase long COVID awareness among physicians. Diagnosis and a standardized treatment plan could help patients avoid unnecessary healthcare utilization and obtain comprehensive support.