I sat in her lounge room on a cold Auckland day in 2007. During our in-depth interview this mother cradled her sick baby while the other three played in a nearby room. They lived in a small two bedroom flat and their son was ill and needed weekly visits to the hospital. Having no car, this journey took them one hour each way by public transport with, three children under seven. No longer was this a bunch of variables in a survey, it was a person’s life and how all these things worked together to make on-time immunisation very difficult.
The interview was part of a qualitative study that seemed elegantly simply. We would recruit 20 parents in three cities who faced economic hardship or social exclusion and whose children were not fully immunised. Then we would find out why.
It had started with a 2006 conversation with a public health practitioner. We both agreed this research was needed. Already, there had sprung up an entire industry of research off the back of the MMR vaccine scare delving into vaccine refusal. But there were another group not immunising on time or at all who were largely ignored. They were poorer, larger and/or single parent families and I suspect many in public health just assumed they knew what was going on. Very few studies had actually asked the families. We wanted to get their story, and their suggestions for what would make timely immunisation easier. We might confirm, unsettle or completely usurp our assumptions about these families. Indeed, part of the fun of qualitative research is being surprised.
The research journey is like a mountain hike at first requiring a trudge through the property of others before embarking on the peaks. There are many gates, many gate-keepers and many paddocks with landowners who require your trust: funding bodies, ethics committees, recruitment sites, journal reviewers and territorial disciplines.
This qualitative project had many gates. First there were the stringent privacy laws making recruitment via the Australian Childhood Immunisation Register impossible; there was an ethics committee who had issues with “statistical analysis” of this qualitative project; there was tiny budget; and the families themselves who were not seen in the typical recruitment settings. We overcame some of these recruitment issues with our first recruitment site, a public health unit, but then swine flu hit and they were swamped. Plan B was to recruit from a population health survey which had capacity to contact these parents. That gate was shut. Plan C involved recruiting through local community playgroups and required a new set of collaborators, a new ethics application and a new set of hurdles.
We ended up interviewing about 45 women in three cities: Sydney, Auckland and Leeds. The women we interviewed were generous with their time, their stories and ideas on how the problem would be solved for them. They became the experts. The mum in Auckland suggested an immunisation service at the hospital, removing the requirement for yet another health appointment on top of an already overcrowded schedule. Other mums living in very difficult circumstances had similarly helpful suggestions.
What was clear was that these mothers supported immunisation and wanted to protect their children. The apathy tag heaped upon them was unfair. In many cases, they faced their own gates and fences which seriously impeded a path they were keen to take. They intended to get their children fully vaccinated but domestic violence, mental illness, housing instability, transport difficulties, and bad experiences with health care services all acted as barriers.
Two days after learning of the failure of recruitment Plan B, I received an email. It was from a from a senior government officer about a large in-depth interview study we did on implementation of their policy. It was written to our small research team.
“The report is great. I must admit to some surprise at how informative and useful the research method has been. I thought we might get some grizzling from the “troops”, but nothing terribly useful. Instead, the report has managed to draw out the concerns of those at the front line and other levels, make sense of them, contextualise them within the whole effort, and make useful recommendations. Fantastic.”*
This is one of the joys of qualitative research – getting to show people unfamiliar with this method just what it can deliver. Far from a series of anecdotes, qualitative research has the capacity to systematically and rigorously provide insights that no other research method can. It helps us ask the “why” questions and can offer a rich understanding of just what is going on:
Why are only one third of pregnant women having a flu vaccine?
What influences people’s perception of cancer risk?
Why do certain groups of women not have pap tests?
What is it like to live with a child with chronic kidney disease?
Qualitative research takes us beyond the t tests and the logistic regression. There is no doubt these quantitative methods play an essential role and it was the surveys that led us to questions about disadvantaged families and immunisation. But qualitative research also gives context and humanity to our research. It would take a lot of locked gates to stop me on this hard but rewarding journey.
*Reported with permission.