Qualitative research methods within the addictions

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; 1996). More recently, et al. 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