The Promise of Qualitative Research to Inform Theory to Address Health Equity

Role of Theory

In health education and health promotion, we discuss the theory of the problem and change theories or theories of action (Glanz, Rimer, & Viswanath, 2015). Theories of the problem are explanatory and help identify and describe determinants of a problem and identify modifiable factors that can be prioritized for change (Glanz et al., 2015). Theories of change inform how to design intervention strategies that will influence priority determinants and also help pinpoint logical short-term and intermediate outcomes for logic models and evaluation efforts (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011; Crosby, Kegler, & DiClemente, 2009; Eldredge, Markham, Ruiter, Kok, & Parcel, 2016; Glanz et al., 2015). Thus, theories provide an organizing framework for our research and practice by systematically guiding us toward constructs to target with our interventions and organize our evaluation and research results.

Despite growing recognition of the importance of broader organizational, community, and policy-related factors in shaping health and health disparities, our field’s tendency to use theories at the individual and interpersonal levels is well documented (Golden & Earp, 2012; Painter, Borba, Hynes, Mays, & Glanz, 2008). Even our program and intervention planning models, which allow for selection of constructs from a range of theories depending on the identified determinants (Airhihenbuwa, 1995; Bartholomew et al., 2011; Green & Kreuter, 2005; Iwelunmor, Newsome, & Airhihenbuwa, 2014), largely rely on our existing theories to shape the questions we ask and how we go about addressing the identified determinants. In the context of informing efforts to pursue health equity, however, the challenge is that few of our theories specify how constructs intersect and interact across levels, and which of these are most powerful in explaining behavior and the environmental conditions that create, maintain, or exacerbate disparities. Moreover, our theories generally do not provide guidance as to which causal pathways are most likely to specifically reduce disparities and in which populations (Diez Roux, 2012).

Additionally, theories at the higher levels of the social ecology are less likely to be operationalized and measured in a manner consistent with our quantitative research methods, which may present barriers to more widespread application. Furthermore, with some rare exceptions (e.g., critical race theory/public health critical race praxis; Ford & Airhihenbuwa, 2010a, 2010b), our existing theories in health behavior and health education neither critically examine nor address the important fundamental causes of health, including the social and political determinants that may be at the root of health inequities. Given the nature of short-term grant and budget cycles (and prohibitions on lobbying with federal funds), it is not surprising that the theories most typically pursued in our field focus on proximal or short-term outcomes and what is perceived as more easily addressable determinants of health. Therefore, as a field, we do not typically recognize or attempt to address historical and ongoing societal factors that have implications for health disparities like racism and power.

The Promise of Qualitative Methods

In considering how qualitative research might advance theory pertinent to health equity, it is first important to recognize that experts approach the application of theory in research from a variety of perspectives. Hennink, Hutter, and Bailey (2011) describe an interplay between deductive and inductive reasoning in their approach and describe how theory is central in the design phase with a clear role in framing research questions and informing conceptual models and frameworks (Hennink et al., 2011). Depending on the goal and context of the research, the analytic process can involve developing inductive theory or applying deductive codes from the research questions, existing theory, or conceptual frameworks. Hennink et al. (2011) argue there is always a theory underlying research and making it explicit is essential, typically in the form of a conceptual framework to guide the research (e.g., categories of questions asked, coding, organization of data, and results; Hennink et al., 2011). Patton (2015) describes theory primarily within the context of sampling and analysis. For example, he describes deductive theoretical sampling for deepening or verifying theory-derived constructs, giving examples such as resilience, trauma, and respect. He also describes inductive grounded theory sampling in which the sample is constructed as the emerging theory begins to take shape and evolves from exploratory to verification. These examples highlight that there is a vast array of opportunities for theory to inform disparities-oriented research.

To date, however, there has been relatively little attention paid to the use of qualitative research to advance theory in the area of health disparities and health equity. The volume of literature describing health disparities and discussing strategies to eliminate health disparities has not made strong conceptual or empirical distinctions between minority health promotion and health disparities elimination (Srinivasan & Williams, 2014). While both outcomes are important and deserve attention, it is likely that each has different determinants and intervention strategies that matter most; as such, the theoretical and conceptual frameworks used to study them may also be different. Furthermore, there are some limitations to relying predominately on a comparative approach that has become the cornerstone of health disparities research in recent years (Bediako & Griffith, 2007). In this context, qualitative methods can play an important role in how we understand and describe the problem of health inequities and their determinants. Not only can these approaches help illuminate social, cultural, and political factors that may underlie health disparities, but qualitative approaches are also uniquely positioned to document and contextualize how these factors affect health across levels of the social–ecological framework in a more nuanced and in-depth way. Qualitative methods also have the potential to illuminate new theories of change, particularly those that operate at higher levels of the social ecological framework, as well as interactions between constructs at varying levels of the framework. Providing insight into how well-accepted theoretical constructs should be operationalized or adapted for specific subpopulations (e.g., social norms, social capital, intention, or attitudes; Burke, Bird, et al., 2009; Pasick, Barker, et al., 2009; Pasick, Burke, et al., 2009) is another potential strength of a qualitative approach. By acknowledging the complex interplay of factors that influence and underlie health disparities, social ecologic approaches that have been informed by qualitative methodologies may provide a good blueprint for moving toward health equity.

While qualitative methods offer these possibilities, according to Hennink et al. (2011), without theory development of some kind, qualitative research ends purely in description, which does not explain a phenomenon and neglects to answer “how” and “why” questions (Hennink et al., 2011). Similarly, Patton (2015) states that “much qualitative inquiry stops at reporting the explanations of the people studied” (p. 583) without attempting further qualitative causal analysis. He further acknowledges that asserting that qualitative analysis can yield causal explanations remains controversial, and this is undoubtedly true in health education and health promotion as well. This may relate in part to the tendency by qualitative researchers to downplay or minimize the generalizability of findings, often due to relatively small sample sizes, which is in sharp contrast to quantitative research that seeks to highlight the generalizability and reproducibility of its findings. However, we encourage our fellow qualitative researchers to go further with our studies and make a concerted (and well-documented) effort to develop, extend, or refine theory within the context of trying to figure out how to reduce health disparities, and when appropriate, to highlight any insights that are consistent with prior work and could be scaled up and tested on a broader scale.

Moving Forward

To make real progress in addressing health disparities and moving toward health equity will require a renewed commitment to and deeper understanding of qualitative research on the part of health disparities researchers in our field. In particular, we encourage researchers to move beyond only descriptive documentation of disparities toward thinking about mechanisms and theory building and refining, with an eye toward informing interventions, strategies, and health promotion messaging in public health and clinical contexts. Through this process, it will be important that researchers refrain from relying only on individual and interpersonal theories, and begin explicitly incorporating behavior change theories with theories at the social, organizational, community, and policy levels, and consider how factors interact synergistically across levels. While we agree that the field should be selective and parsimonious with respect to the development of new theories (Glanz et al., 2015), we also assert that with respect to promoting health equity, there is room for the development of new theories and refinement of theoretical constructs, particularly for those pertaining to the social, organizational, community, and policy levels.

Building theoretical and conceptual frameworks and models that can be applied across multiple levels is highly pertinent to disparities research in several ways. First, these theories are more likely to address the larger societal and social factors that shape disparities and can help researchers identify which factors matter most across levels (e.g., what is most relevant and meaningful for a population), and should therefore be prioritized as intervention or policy targets. While most research to date has focused on using qualitative research to provide insight into the populations experiencing inequities, we recommend researchers use qualitative research to advance understanding of “behaviors in context,” and the settings and social context in which disparities arise (Burke, Joseph, Pasick, & Barker, 2009; Okechukwu, Davison, & Emmons, 2014). This includes investigating the contexts in which interventions to address disparities are implemented, with an eye toward theory building and theory refinement.

Second, we encourage researchers to move beyond approaching health disparities largely as a single dimension toward considering the possible intersectionality of social dimensions that have implications for health equity (Bauer, 2014; Bowleg, 2008). Using qualitative research that is grounded in the daily experiences of people’s lives may help address the methodological challenges of thinking about social categories as additive and instead frame them as related and intersecting social structures that create and recreate social disadvantage and health inequity. There are also many opportunities for researchers to use more community-engaged, participatory, and action-oriented theories and frameworks that not only focus narrowly on health disparities but also encourage an assets-based approach that focuses on promoting health equity (Grieb, Smith, Calhoun, & Tandon, 2015; Wallerstein & Duran, 2006). This Commen-tary is consistent with Bowleg’s (2017) Perspective in Health Education & Behavior, which advocates for the wider use of critical theoretical frameworks in health equity research. In making advances in this area, it is also clear that we have much to learn from other disciplines that have rich histories in both theory and qualitative research, including anthropology, history, and sociology (Chowkwanyun, 2011; Hirsch, Wardlow, & Smith, 2009; Livingood et al., 2011; Livingood, Allegrante, & Green, 2016; Nathanson, 2007; Pasick & Burke, 2008). Of note, these fields have also incorporated a much broader range of qualitative approaches in their research (e.g., textual analysis, comparative ethnography) that we encourage researchers to explore and embrace.

Finally, we recommend that in examining health disparity issues, researchers in this area be thoughtful and detailed in the social dimension and lenses through which they are grouping “disparity” populations, as there is tremendous diversity and heterogeneity within groups (e.g., documented differences among Latinos in health disparities and determinants of health by country of origin; Shelton, Jandorf, Thelemaque, King, & Erwin, 2012). This will help increase the likelihood that interventions will be developed or adapted with cultural specificity when needed (e.g., when the determinants are unique to that population) or will help identify when there are commonalities across social groups that can be addressed across disparity populations (Emmons, Barbeau, Gutheil, Stryker, & Stoddard, 2007; Goldman et al., 2003). In addition, qualitative research can be used to inform the operationalization and measurement of constructs that may be newly identified within a social context and/or are culturally specific (Airhihenbuwa, 2006; Airhihenbuwa & Liburd, 2006).

In conclusion, we believe there is much work to do to make progress in both eliminating health disparities and promoting health equity. In fact, in examining qualitative research focused on promoting health equity, the majority of research, including the rich scholarship featured in this special issue, focuses on the methodological and intervention implications of their research findings. However, we also believe that there are tremendous opportunities for qualitative and health equity scholars to advance research and practice in this area through the expansion and application of rigorous, theoretically informed qualitative research. We hope researchers will recognize and seize this challenging, but critically important opportunity.