JOURNAL OF ADOLESCENT HEALTH 1999;25:371–378
COMMENTARY
The Reason and Rhyme of Qualitative Research:
Why, When, and How to Use Qualitative Methods in
the Study of Adolescent Health
MICHAEL RICH, M.D., M.P.H., AND KENNETH R. GINSBURG, M.D., M.S.ED.
Qualitative Inquiry in Adolescent Health
Many of the life experiences, understandings, and
beliefs that place young people’s health at risk are
difficult to quantify, yet adolescent health providers
must assess and evaluate them. Qualitative research
offers tools to examine these powerful forces at work
in young lives. It looks beyond diagnostic outcomes
to explore context and motivation, the “how” and the
“why” of adolescent health risk behaviors. Although
qualitative methods are relatively new to medical
and public health research, clinicians use qualitative
techniques every day: observing, actively interviewing, receptively listening, evaluating narratives, integrating data from diverse sources while recognizing
inherent biases, and analyzing the information in a
flexible and critical manner. This intuitive use of
qualitative techniques informs clinicians how to vary
their interactions subtly to best meet the differing
needs of their patients. This “art of medicine” combined with biomedical science allows clinicians to
move beyond medical problem solving and become
healers. The goal of all research is to enhance a
knowledge base. By furthering clinicians’ understanding of human factors that influence adolescent
health, including social context and the patient perspective, qualitative research (1– 4) enhances the type
From the Division of Adolescent/Young Adult Medicine, Children’s
Hospital/Harvard Medical School, Boston, Massachusetts (M.R.); and
the Craig-Dalsimer Division of Adolescent Medicine, The Children’s
Hospital of Philadelphia, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania (K.R.G.).
Address reprint requests to: Michael Rich, M.D., M.P.H., Division
of Adolescent/Young Adult Medicine, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115.
Manuscript accepted May 21, 1999.
of knowledge that allows us to more effectively
prevent unhealthy behaviors and, ultimately, to heal
disease.
Pursuing an Answer: Quantitative and
Qualitative Paths
The scientific method, observation, hypothesis generation, and hypothesis testing, is the central structure of both quantitative and qualitative inquiry.
They share an investigative approach that poses a
question, collects and analyzes data, and presents
results. Scientific rigor and the integrity of a theoretical framework are critical to both. Although quantitative and qualitative research are often presented
as being diametrically opposed, this polarization is
both artificial and inaccurate. Quantitative researchers have viewed qualitative research as lacking scientific rigor, and qualitative researchers have believed that quantitative researchers were missing the
human element. Recently, however, there is growing
recognition that the two fields complement each
other and that the greatest strides toward improved
health can be made when both methods of inquiry
respond to a problem (5–10). No research approach is
complete or flawless; quantitative and qualitative
methods have different strengths and limitations.
A first step toward deciding the appropriate
methodological path is to focus on the essential
question the research intends to answer. Any study
of adolescent health issues tries to answer one or
more of the following basic questions: What? When?
Whether or not? How many? To whom? How? Why?
Quantitative methods offer the best and most verifi-
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RICH AND GINSBURG
able answers to the more concrete questions of
“what,” “when,” “whether or not,” and “how many”
phenomena occur. In the earliest stages of research,
however, “what” to study is sometimes not clear. In
that case, qualitative inquiry can be used to uncover
problems and generate hypotheses. Quantitative research can answer “to whom,” but is limited in its
ability to describe people. While it can indicate what
happens to people from differing demographic
groupings, quantitative inquiry lacks the ability to
look at the complex interplay among factors that
produce individual choice or behavior. Although it
cannot look for trends among large groups, qualitative research is an ideal approach to elucidate how a
multitude of factors such as individual experience,
peer influence, culture, or belief interact to form
people’s perspectives and guide their behavior. Most
importantly, qualitative methodologies can offer far
greater insight into “why” and “how” phenomena
occur than can quantitative methods.
Next, the researcher must consider the way in
which the philosophies, perspectives, and tools of
quantitative and qualitative modes of inquiry differ.
In general, quantitative methods work with discrete,
numerical data, analyzing their frequencies and statistical associations, while qualitative research examines narratives, meanings, and behaviors in social
context. Medical and public health research has
traditionally been conducted under the positivist
paradigm, which assumes that reality is objective
and quantifiable. Quantitative researchers stand outside their subject, measuring external manifestations,
approaching phenomena from the outside in, using
objective, tangible variables. Numerical values are
assigned to phenomena and validity is achieved
through measuring enough cases that the results
become statistically significant. The quantitative approach is ideal for studying biomedical phenomena
such as the body’s response to a medication, or
epidemiological trends such as the increasing prevalence and morbidity of asthma.
While quantitative research can tell us much
about the incidence and outcomes of disease, it
cannot answer how to get patients to use medication
when it does not make them feel better, or why,
despite improving medical technology, asthma is
getting worse. The health and risk behaviors of
adolescents are clearly affected by social, psychological, economic, and cultural forces. Successful health
care depends as much on the human nature, life
experience, beliefs, and motivations of the patient as
on offering the best medicine. Based on the assumption that reality is socially constructed, complex, and
JOURNAL OF ADOLESCENT HEALTH Vol. 25, No. 6
constantly changing, qualitative research investigates behaviors through the human perceptions,
understandings, and beliefs that motivate them.
Qualitative investigators seek to understand their
subjects from the inside out. Inductive rather than
deductive, qualitative methods are designed to study
a particular phenomenon, group, or behavior in
depth to reach a better understanding of the universal. The qualitative researcher often works with a
small sample size, deriving detailed information on
participants in their living contexts, gaining “thick
descriptions” (11) of specific situations or case histories, seeking patterns in complexity rather than a
simplifying consensus overview.
Qualitative research methods search for answers
from the broader social context rather than isolating
the subject of study. Factors that might be considered
confounders to quantitative methods may be embraced in qualitative research; their interrelationships are explored as part of the complex whole
being studied. Qualitative inquiry can generate hypotheses as well as test them, starting with a blank
slate and developing theory gradually from the data
(12). Where quantitative methods achieve rigor in
part by fixing the hypothesis and the method for
testing it at the outset of a study, qualitative inquiry
finds richness and depth by following the subject
matter where it leads.
Collecting Qualitative Data
The closer to the natural state in which health research data are collected, the fewer limitations exist
in translating the findings into real-life applications,
but the greater probability that the collected data
may be biased by investigator perspective. For example, behavioral research can be conducted on neurotransmitters in a laboratory environment, where it is
highly controlled, but many steps need to be taken
before experimental results can be applied to humans. A behaviorist who integrates into a study
population, participating fully in all activities, is
observing behavior in a more naturalistic setting.
However, to pursue such research with minimal
alteration of population behaviors requires sensitivity and careful technique. In general, qualitative
research is far more naturalistic than quantitative
research, but even within qualitative inquiry, the
proximity to the naturalistic environment and the
degree to which the investigator changes the environment can vary.
Most research struggles to move toward the nat-
December 1999
uralistic setting, but ethics, cost, and even safety
often necessitate a stepwise compromising approach.
For example, a research pharmacologist first tests a
drug in a test tube, knowing the effect may not be
predictive of the same effect in humans, but risking
no lives. If the test results are as hypothesized and no
unforeseen problems arise, the drug will be tested on
an animal model and, ultimately, humans. An example more relevant to adolescent research is the gathering of the youth perspective. The written survey
collects opinions, but it is less than optimal because
people do not form opinions on paper; rather, they
do so through conversation or life experience. Collected opinion becomes more natural when transformed into conversational form by means of the
interview. Another natural setting is found in a focus
group, where questions are asked of groups that
create the give-and-take atmosphere in which opinions naturally form. The most natural setting to
gather opinions might be through participant observation, by which the researcher can observe realworld groups for interactions that formulate and
actions that reflect opinions.
Qualitative research methods recognize the primacy of the subject of inquiry. The research question
and the nature of the data determine and guide the
methods used. Well-established as research tools in
other fields of human study such as anthropology,
sociology, and education, there is a wide variety of
qualitative methods of which this overview can
discuss only a few. Qualitative data may consist of
field observation in the participants’ natural environments or other milieux, oral or written narrative,
text, sounds, and/or visuals. Many qualitative studies use more than one type of data and collection
technique to enrich and add perspective to the pool
of information on their subject of inquiry.
When researchers are investigating health risk
behaviors and their underlying belief systems and
motivations, interviews may be an effective means of
data collection (13,14). Interview protocols may
range from precisely worded scripts that are repeated with each participant to semistructured conversations, in which broad initial questions elicit
participants’ responses, which in turn generate further questions, following the unique flow of ideas
that occurs with each participant. Those that follow
precisely worded scripts can generate quantifiable
data similar to those collected via a survey. Advantages of collecting data by interview rather than
survey are the more naturalistic setting and the
elimination of literacy as a limitation; a disadvantage
QUALITATIVE METHODS
373
is that people may be more comfortable telling the
truth to a piece of paper than to a person.
Focus groups, a variation on the interview in
which a group is asked for responses to and discussion of research questions, may prove useful when
examining consensus beliefs or group behaviors such
as binge drinking (15–17). Different types of focus
groups use a variety of techniques to balance the free
flow of ideas while limiting the biasing effects of
group dynamics. For the purpose of adolescentbased research, two techniques are most appropriate.
The open focus group uses a facilitator to guide a
group of participants through a discussion focused
on a specific issue. Nominal Group Technique is a
one-question method in which a group generates
and prioritizes solutions to the question; it uses a
tightly structured format designed to limit group
dynamics.
Ethnographic study of an adolescent subculture
might obtain data by means of participant observation (18,19), where the researcher observes people
and their behaviors from within the social matrix of
their worlds. The researcher explores environments,
participants, and events from a perspective that can
range from marginal observer to full participant. In
suburban malls or on inner-city streets, for example,
one can examine and experience the rituals of adolescents’ lives from within their worlds. With participant observation, the researchers themselves become instruments of data collection, studying the
participants’ lived experience by observing, feeling,
responding to, and noting their own perceptions, as
well as more objective observations of study participants and their behaviors.
Where the inquiry is concerned with the meaning
of illness, relationships, or sexuality, the data might
be collected through semistructured interviews, journals, or other participant-generated narratives. The
forms that narratives take may be culturally or
linguistically based, they may be oral or textual,
preexisting or elicited by the researchers. Cultural
documents, such as newspapers, magazines, and
radio or television broadcasts may be studied (20), as
well as more personal or group-specific artifacts,
photographs, letters, graffiti, and video or audio
recordings. Self-documentation, in the form of diaries, poetry, photos, or videos created by research
participants, can give them voice and independence,
allowing participants to become collaborators in the
research (21). Whether created independently by the
participants or motivated by the researchers, these
personal documents can be analyzed for the objective features of participants’ lives, worlds, relation-
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ships, and experiences, but also for what they reveal
of the participants’ subjective perceptions, understandings, meaning making, and inner lives.
Analyzing Qualitative Data
Because the goal of qualitative research is to derive
rich descriptions of the world and of human experience, subjects of inquiry which are nonlinear and
multidimensional, qualitative data are often analyzed from multiple perspectives using different
analytical methods (22–24). Analysis begins with the
initiation of data collection and continues and
evolves throughout the course of the research
project, responding to the nature of the findings as
the phenomenon being studied is better understood.
Like data collection, analysis often evolves and
changes as the study progresses to derive the richest,
most complete findings and to improve the internal
validity of the study. Some methods of analysis
consider data in their pure, raw forms as direct
delivery of experiences, thoughts, and behaviors to
the researcher’s theoretical framework. Contextual
analysis looks at the data as a whole, while categorical analysis organizes and codes data by ideas or
themes. As with quantitative research, qualitative
methods benefit from explicit, well-organized data
collection, management, and analytic procedures so
that the research process is clear and may be replicated, so that the findings and conclusions are verifiable, and so that scientific fraud can be tracked.
Data analysis consists of four linked processes: data
reduction, data display, conclusion drawing, and
verification (22).
Data reduction can occur both in an anticipatory
way, by collecting the data within a conceptual
framework which focuses and bounds the subject of
study, and after the data are collected, by summarizing, coding, and organizing the data by themes or
within narratives. The goal of qualitative inquiry is
to determine and explain a pattern of relationships
that may best be analyzed by grouping the data into
conceptual categories, either predetermined or arrived at through the accumulation of data. Theoretical frameworks that guide this grouping of the data
can include one or more of the following:
• narrative analysis (25)— understanding human
motivations, perceptions, and behavior by interpreting the stories people tell of themselves and
their experiences
• ethnography (26)—studying people through the
nature of their social structures and behaviors
JOURNAL OF ADOLESCENT HEALTH Vol. 25, No. 6
• medical anthropology (27)—analyzing how people understand and respond to health and illness
through their filters of culture and belief
• phenomenology (28)— understanding humans
through the meanings they attach to experience
• grounded theory (29)—theory that is not predetermined but is gradually developed from,
evolves with, and is tested against the data collected.
Data display codes, organizes, and structures the
compressed data into theory-guided synopses, patterns, or matrices so that they can be viewed and
arranged into a logical whole. This display and
arrangement of data can be done manually or by
computer. Manually, the data groupings can be
placed on index cards for arrangement into a logical
pattern, then transferred into graphic form as a grid
or flow sheet with arrows indicating the directions
and (sometimes) magnitude of effect. Narratives or
other text can be read and analyzed for meanings
and motives. Audio or video recordings can be
reviewed and coded for elements of research interest.
Use of computer software allows for rapid, consistent, and comprehensive analysis of large amounts of
data. However, software packages for qualitative
analysis are based on theoretical structures of which
the researcher must be aware and use appropriately.
QSR NUD*IST (30) and The Ethnograph (31) code
and organize data in a series of hierarchies (e.g., A is
an overarching category which includes the general
area of B, under which resides the subset of C), while
ATLAS.ti (32) and HyperRESEARCH (33) connect
data in a network of links with varying directions,
intensity, and temporality of relationships (e.g., A
makes B possible, B mitigates C, which can only
occur after A is completed).
Display of qualitative data for analysis presents a
potential increase in “the primary risks to the adolescent participant from behavioral research [which]
are potential embarrassment and/or disclosure of
sensitive information to others” (34). Because qualitative research methods obtain such detailed information, from life stories to relational maps to photos
and videos, participants risk a loss of personal privacy even with names, hospital numbers, or other
traditional identifiers stripped from the research
record. The storage, display, and analysis of qualitative data must be accorded the highest security and
researchers must respect the privacy of their research
participants by keeping all research data and findings strictly confidential.
Conclusion drawing is the derivation of findings
December 1999
from the theory-structured patterns of data. Ultimately, meaning is found by discovering universal
relationships that can be found in the natural and
social worlds. Often several evaluations of the data
are required for findings to be identified and defined, and their importance clarified. Model building
is based on the evolving domains of data that emerge
from the analysis process. Qualitative methods can
result in multiple findings, related or unrelated,
hypothesized or unexpected, from within the theoretical bounds of the research question.
With careful analysis, qualitative inquiry can
move beyond associations to causality. “. . . we get
inside the black box: we can understand not just that
a particular thing happened, but how and why it
happened” (35). Because qualitative methods can
develop and modify theory as well as test it, they can
examine influences and events longitudinally, test
proposed causal mechanisms against emerging and
evolving theory, and suggest how a temporal series
of events may lead to a specific outcome. Although
qualitative studies may be prospective in design,
assessing causality must be retrospective because
this is the only means of viewing the narrative
sequence. Analysis is “a retrospective gathering of
events into an account that makes the ending reasonable and believable . . . configur[ing] the events in
such a way that the whole story becomes clear” (36).
Verification is the process whereby interim findings and conclusions are verified and tested against
the data, a process for which clear and complete data
display is critical. All data collected are compared
against each other and against the resultant conclusions to reinforce or contradict, enrich or rule out the
researcher’s analysis and emerging findings. The
process of verification is ongoing, starting with data
collection. The researcher adopts a reflective stance
from which to learn, respond, and test findings
against the incoming data stream, sometimes even
checking perceptions and interpretations with study
participants. This series of question-and-answer cycles, the iterative process, operates as an ongoing
dialogue between data collection and analysis. The
application of multiple research approaches, triangulation, is a concept derived from navigation where
different bearings taken from different angles can
precisely locate and characterize a feature in three
dimensions (37). Triangulation can include the use of
different data sources, researchers, theoretical frameworks, or methodologies directed toward the subject
of research inquiry (38). The multidimensional findings that result can be used for internal verification
and further modification of theory and conclusions.
QUALITATIVE METHODS
375
Conclusions drawn must be supported by ongoing
iteration. Theories that emerge must be responsive to
and modifiable by the analytical process. Ultimately
they must explain, interpret, and be able to predict
outcomes.
Bias, Reliability, and Validity in Qualitative
Research
Scientific rigor is necessary for any research method
to understand and accurately represent the phenomena it studies. The first level of scientific rigor is
achieved by using a research method appropriate to
the subject matter. Few would argue that a tightly
controlled laboratory experiment is the ideal method
for studying a social phenomenon. The key to
achieving rigor in any research is to maximize methods that are most sensitive to the subject studied (39).
Bias is at work in all research. The influence of the
researcher, the research question, and the method
can never be completely neutralized. Qualitative
researchers can recognize and minimize the potential
for bias inherent in their methods. Facilitators of
focus groups are trained to understand and compensate for their own personal biases, to promote equal
participation of all group members, and to decrease
the biasing effect of group dynamics created by
power differentials, transference, and psychosexual
issues. Participant observers are trained to fit in
while minimizing their influence over routine occurrences. Acknowledging that subjectivity cannot be
completely eliminated, the reflective, questioning
process of qualitative investigation actively observes,
evaluates, and counterbalances the influences that
bias may have on data collection, analysis, or the
drawing of conclusions (40).
Reliability, the consistency with which a research
method measures a phenomenon, is a concept from
the physical sciences which becomes more difficult
to operationalize when the subject of study, social
reality, is in constant flux. Even though the social
landscape may change, there are properties of human experience, perception, and response that are
stable. In evaluating these properties, qualitative
methods can achieve diachronic reliability, the reproducibility of an observation at two different times,
and synchronic reliability, agreement of observations
from two or more perspectives at the same time (39).
Qualitative methods achieve diachronic reliability
through careful record keeping and, if possible,
through multiple observations of a repeated event.
Pretesting and standardizing instruments and train-
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ing data collection personnel can significantly improve reliability. Transcripts, photos, and audio or
video recordings can be analyzed and reanalyzed at
different points in time. Synchronic reliability can be
improved by evaluating data collection for areas of
congruence among independent observations by different observers, known as interrater reliability (23).
Standardized data collection protocols and comparisons of different observations are key tools for
maximizing qualitative reliability.
Validity, the accuracy with which a research finding represents the phenomenon studied, is improved
in quantitative studies by eliminating or controlling
for variables that might affect the phenomenon.
Since the artificiality of the laboratory setting is
inappropriate to social research, and since variables
may be part of the process being studied rather than
confounders, qualitative researchers must learn as
much as possible about the study phenomenon and
its environment, evaluating their findings for credibility and consistency. Multiple types of data, collected through different means and analyzed
through different theoretical frameworks, are triangulated to situate the phenomenon studied and
increase the validity of findings. Hypotheses, conclusions, and developing theory are constantly tested
against the data for refutability, “exposing to falsification, in every conceivable way, the system to be
tested . . . to select the one which is by comparison
the fittest, by exposing them all to the fiercest struggle for survival” (41). Using analytic induction, a
standard qualitative validation procedure, hypotheses are not accepted or rejected, but are modified and
reformulated in response to the data until the theory
fits the data (23). In an iterative process known as
respondent validation, conclusions drawn and theories developed from the data are taken back to study
participants to be verified, modified, or rejected (42).
Finally, to counteract any concern that data have
been selected because they support the researcher’s
argument, the frequency of observations can be
counted as a means of surveying the whole body of
data to determine whether the detailed results of
qualitative inquiry are likely to be representative of
the population at large (23). The ability to generalize
findings and theories developed from a small number of cases to a larger population confers both
research validity and clinical applicability.
Qualitative Research in Adolescent Health
Adolescence is a time of great physical, psychological, and social flux. Consequently, the lives and well
JOURNAL OF ADOLESCENT HEALTH Vol. 25, No. 6
being of youth are disproportionately jeopardized by
behavioral choices. Given the importance of adolescent lifestyles and risk behaviors to their health,
adolescent health is full of potential applications for
qualitative research. Adolescence has social ordering, values, cultures, and languages of its own. What
an adult considers to be risk behaviors may have
totally different meanings to an adolescent. They
may be part of a complex coping strategy, and may
in fact be adaptive for youth. For example, nicotine
may relieve anxiety. The stoicism created by prolonged use of cannabis may offer a needed respite
from a stressful existence. Violence may release
pent-up anger. Sexual activity may offer an alternative to a lonely existence. The adolescent lifestyle
incorporates structured patterns of behavior, including risk behaviors and other activities that affirm
independence from parents (43), and must be understood as a whole for individual behaviors of concern
to be addressed effectively.
Since their earliest applications in social science
research, qualitative methods have been used to
investigate adolescence. Anthropologist Margaret
Mead explored “coming of age” in South Pacific
cultures (44,45), and a major early work in sociology
was a study of a teen prostitute by W. I. Thomas (46).
Recently, qualitative methods have been used to
evaluate adolescent lives and the ways that they are
influenced by gender (47), class (48), and race (49).
They have been applied to the investigation of living
with chronic disease (21,50) and health-related social
phenomena such as juvenile delinquency and social
deviance (51), substance abuse (52,53), sexual behaviors (54), and teen parenting (55,56).
Study and surveillance of adolescent risk behaviors remain the cornerstone of adolescent health
research. These data awaken policy makers to the
scope of the challenges confronting adolescent health
and guide clinicians and advocates where to focus
resources. Of equal importance, research efforts must
document the strengths of adolescents so that a base
of knowledge exists about protective as well as
harmful factors. The ultimate objective of these efforts is to develop effective, appropriate strategies to
steer youth toward healthier, safer futures. These
interventions are far more likely to be successful if
they are informed by a research base that includes
complementary quantitative and qualitative data.
Adolescent behavior is tightly linked to life experience and social context, what feels right to them, and
what they believe their peers are doing. Designing an
intervention for a behavior that adults have determined to be negative without understanding the
December 1999
adolescent life context in which that behavior developed is predictive of failure. Alternatively, attempts
to limit dangerous behaviors while bolstering or
generating safer protective behaviors that offer
youth the same adaptive benefits may offer greater
chance of success. Initial steps in developing intervention strategies must employ qualitative research
methods to gain a contextual understanding of
youth, their behaviors, and the natures of their lives
and worlds. As intervention strategies are implemented, rigorous quantitative and qualitative outcome measures are needed to demonstrate those
strategies that are and are not working, as well as
when and for whom they are most effective.
Qualitative methods have direct applications to
adolescents’ interactions with the health care system.
As an example, adherence is an easily measured
variable; one does or does not follow clinician instructions. Yet, out of social context, strategies for
improved adherence are difficult to develop. Qualitative methods offer the clinician an opportunity to
understand illness and the burden of medical selfmanagement as experienced by the patient. These
methods can be effective at illuminating patient
experiences, perceptions, and understandings of
their health and medical care (57). Qualitative inquiry can even allow adolescents to document
and invite the clinician into their lives with illness
(58).
Qualitative research can offer youth a forum to
guide health practitioners to better serve them. Most
research that explores satisfaction or health-seeking
behavior uses investigator-written surveys. Because
investigators are adults, the teen point of view is
often missed. Thus, research that does not include
adolescents in the generation of ideas has the potential to miss adolescent concerns critical to their use of
health services. Furthermore, satisfaction surveys
generally undergo quantitative analysis that is able
to derive the names of those variables that are most
important. However, adult-named variables have
limited meaning to clinicians who wish to incorporate them into daily patient encounters with adolescents. Knowing that privacy or honesty is of great
importance is helpful, but knowing how youth understand these concepts and wish to be assured of
their presence is critical. Qualitative research can
ensure that areas of greatest concern to adolescents
are explored, and that adolescents have the opportunity to describe their concerns and make them
meaningful to clinicians (59,60).
QUALITATIVE METHODS
377
Final Thoughts
Adolescence is a time of ferment and potential, of
energy and of turmoil, of confusion and of creativity.
It is a time of taking risks and of dreaming idealistic
solutions. Qualitative modes of inquiry can offer an
adolescent-centered view into this complex world.
This view may allow us to better work with
youth—to draw on their strengths, build on their
idealism, and guide them toward safer behaviors.
Our vision of the direction for adolescent health is
likely to be clearest when adolescents serve as our
guides, for they best understand the prose and the
poetry of their lives.
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