| Abstract|| |
The use of Qualitative Research (QR) methods are now getting common in various aspects of health and healthcare research and they can be used to interpret, explore, or obtain a deeper understanding of certain aspects of human beliefs, attitudes, or behavior through personal experiences and perspectives. The potential scope of QR in the field of dental public health is immense, but unfortunately, it has remained underutilized. However, there are a number of studies which have used this type of research to probe into some unanswered questions in the field of public health dentistry ranging from workforce issues to attitudes of patients. In recent health research, evidence gathered through QR methods provide understanding to the social, cultural, and economic factors affecting the health status and healthcare of an individual and the population as a whole. This study will provide an overview of what QR is and discuss its contributions to dental public health research.
Keywords: Dental public health, qualitative, quantitative, research methods
|How to cite this article:|
George RP, Kruger E, Tennant M. Qualitative research and dental public health. Indian J Dent Res 2012;23:92-6
Qualitative research (QR) methods are now common in research into the sociocultural aspects of health and healthcare  and in the development and evaluation of health policy.  It has been increasingly recognized in recent years as having a distinctive and important contribution to make to dental research.
The definitions for QR are diverse. These range from an emphasis on the methods and techniques of observing, documenting, analyzing, and interpreting attributes, patterns, characteristics, and meanings of specific, contextual, or gestaltic features of phenomena under study through approaches which seek to uncover the thoughts, perceptions, and feelings experienced by informants, to the view that inquirers discover knowledge that is literally created by the action of the inquirers with the object inquired into. 
QR gives way to ask different research questions and explore and understand phenomena from a contrasting perspective like the "what," "why," and "how" questions about a phenomenon. , Research in dentistry has predominantly been quantitative in nature, fuelled laterally by the drive toward evidence-based dentistry.  But nowadays, there is an increasing use of QR methods in public health dentistry, although its utilization and awareness are limited.
This study will provide an overview of what QR is and discuss its contributions to dental public health research.
| Quantitative Vs Qualitative|| |
Quantitative research methods provide quantified information and answers to research problems and are associated with positivistic experimental research.  They can be used to establish a cause-effect relationship and incidence of a disease (e.g., role of Streptococcus mutans in dental caries), to test experimental hypothesis (e.g., fluoridation reduces dental caries), to determine the effectiveness of interventions or treatments (e.g., brushing techniques), or to determine opinions, attitudes, or practice of a large population (e.g., how often people attend a dental practice). ,,
In contrast, QR does not seek to provide quantified answers to research questions and tends to be a more naturalistic type of research. It can be used to interpret, explore, or obtain a deeper understanding of certain aspects of human beliefs, attitudes, or behavior such as people's personal experiences and perspectives (e.g., factors that influence dental attendance). ,, It is the ideal suited method of research where little is known or understood  or where quantitative research methods cannot be applied (e.g., dental fear) and can overcome literacy problems where children, minors, or illiterates are involved. , QR can be very effective to develop hypothesis in newly emerged or under-researched areas which can be later tested by quantitative research  and can also be used to explore the meaning of already explored quantitative data in more detail where data are conflicted or unexpected. ,
| Methodology in Qualitative Research|| |
Quantitative research proceeds in a scientific, objective, and value-free way to enumerate generalizable findings, whereas on the other hand, QR focuses on social meanings and the methodologies utilized, aiming to access these social meanings. 
The methods of data collection in QR are in-depth interviews, focus groups, observation, and documentary analysis, although the first two are more commonly used.
The choice of method depends on a number of issues such as the research question, practical issues such as ease of access, the relative importance of social context, the depth of individual perspective required, and the sensitivity of the subject matter. 
Qualitative in-depth interviews
Interviews in QR are different from the structured interviewing techniques in quantitative research and the interviewer has a more passive, adaptive role, giving direction to topic areas,  allowing expression of understandings and health behaviors of the subject  and providing an atmosphere in which participants are more willing to be open about behaviors and attitudes. One example in dental public health is when school children were interviewed about food choices and preferences which influence oral health through semi-structured interviews.  The influence of peer pressure was subsequently confirmed which was not previously thought of. Interviews can offer a rich source of data;  however, practical constraints due to time, research agendas, financing, and access mean that semi-structured qualitative interviews are more often used. 
A focus group can be defined as a group discussion on a given topic organized for research purposes which is guided, monitored, and recorded by the researcher.  Focus groups generate information on collective views and the understanding, experiences, beliefs, and meanings that lie behind those views. , The discussions are not structured and generally move from a more general to specific issues related to the research agenda where the role of the moderator or the researcher is quite crucial. Focus groups in dental research are recommended in a number of areas relating to patients, dental services, and the dental profession. For example, they have been used to explore barriers to services among minority ethnic groups and also to investigate the oral health-related attitudes of drug users. 
Observation is the systematic watching of people and events to find out about behaviors and interactions in natural settings where the researcher is the research instrument, engaged in watching, joining in, and talking, in order to study everyday settings. , The researcher can either join the study population and experiences phenomena for himself or just watch the participants and remain independent.  Observing patients' behavior, especially signs of fear or anxiety, in the waiting room of a dental surgery  and participant observation to study how dentists interact and behave with their patients are a few examples.
This method involves documents that have been either solicited for the purposes of the research  (e.g., participants keeping a diary or writing an account specifically for the research) or documents which already existed (such as textbooks or magazines). , These have now evolved to use of websites, message boards, etc.
| Sampling Methods in Qualitative Research|| |
Choosing participants and selecting a sample is one of the important aspects of any research methodology. Statistical sampling methods and randomization used in quantitative research is uncommon in QR methods.  Systematic non-probability methods are used to identify individuals with characteristics of relevance to the study, in order to facilitate the exploration of a particular aspect of behavior.  However, these sampling strategies tend to be systematic, based on certain set criteria which are designed to select the most appropriate sample for a given project. For example, in a research to understand the factors influencing the decision making of oral surgeons to remove impacted third molars, qualitative interviews may be required before a questionnaire-based QR. However, not all oral surgeons can be included and therefore a convenience sample can be chosen to be interviewed based on whose answers a questionnaire can be drafted for quantitative research.
| Analysis of Data in Qualitative Research|| |
The two fundamental approaches to analyze qualitative data are the deductive approach and the inductive approach. ,
The deductive approach involves using a structure or predetermined framework to analyze data. Essentially, the researcher imposes their own structure or theories on the data and then uses these to analyze the interview transcripts.  This approach is useful in studies where researchers are already aware of probable participant responses.  However, although this approach is relatively quick and easy, it is inflexible and can potentially bias the whole analysis process as the coding framework has been decided in advance, which can severely limit theme and theory development.  For example, in a study exploring patients' reasons for complaining about their dentist, the interview may explore common reasons for patients' complaints such as trauma following treatment, discomfort during treatment, communication problems, and other related issues. 
Conversely, the inductive approach involves analyzing data with little or no predetermined theory, structure, or framework and uses the actual data itself to derive the structure of analysis.  This approach is comprehensive and therefore time-consuming and is most suitable where little or nothing is known about the study phenomenon. Inductive analysis is the most common approach used to analyze qualitative data. ,
Qualitative research and evidence-based dentistry
Though QR is capable of being used as a methodologically sufficient approach in its own right, as a precursor to quantitative studies, during or after trials to explain processes and outcomes, and as a means of enhancing the link between evidence and practice, it has been little used as an evidence resource for systematic reviews.  It is debated or thought to lack the scientific rigour for it to be considered as an evidence base.
Systematic review is one of the cornerstones of evidence-based medicine and several researchers have begun to address the issue of developing a qualitative variant. Although some reviews seem to consider QR in hierarchy for healthcare evaluation and effectiveness studies, there still remain several issues that need to be addressed in making the role of qualitative evidence in reviews more systematic. Certain approaches to meta-analysis are offering hope of synthesizing qualitative forms of data to provide evidence.
For a research done using qualitative data to make a significant contribution within evidence-based dentistry, the advocates of the QR must demonstrate its ability to address questions of relevance to practice , and the supporters of evidence-based dentistry must rethink their ideas as to what may constitute a research question. ,
| Weaknesses of Qualitative Research|| |
The most common logistical problems associated with QR are that it is time consuming and expensive. ,,,
The other issue is the problem with sampling  as the recruitment criteria are not clear and nonrandomized as in quantitative studies. There are also problems with data collection as the conduct of focus groups or interviews may not be scientifically perfect when compared with the data collection methods in quantitative methods.  Researcher bias , is another issue to be addressed in QR which questions the reproducibility of the findings. There are also problems with analyzing and presenting data as the volume of data collected is enormous and attributive error is a major hurdle to scientific reporting.  The data analysis process is arguably more subjective,  thus leading to the issue of the verifiability.  Unfortunately, despite perpetual debate, there is no definitive answer to the issue of internal and external validity of qualitative analysis and research on the whole.
There has always been a lack of consensus on the characteristics of good QR. The debate reflects the fact that there is no single, accepted way of conducting QR as researchers using qualitative methods come from a wide variety of philosophical traditions, and differ in their beliefs about the nature of reality, facts, values, and knowledge. 
| Contributions and Examples of Qualitative Research in Dental Public Health|| |
The potential scope of QR in the field of dental public health is immense, but unfortunately, it has remained underutilized. However, there are a number of studies which have used this type of research to probe into some unanswered questions in the field of public health dentistry. It can be proved that QR can be used to answer a wide range of questions ranging from workforce issues to attitudes of patients.
Quite a number of studies have been done using QR methods in children where absolute quantitative data are difficult to measure. One such study throws light on the dental health beliefs of mothers on their child's oral health and this was carried out by unstructured interviews.  Another study combined interviews and focus groups to identify barriers to the development of an integrated approach to caries prevention in young children. This study helped gain more information from healthcare professionals and it revealed the fact that the focus was more on dental pain due to the pressures of time and the need to address the immediate need, and this in turn had prevented the appreciation of the broader psychosocial impact of oral health on the young population.  Qualitative interviews have also helped to identify the perceptions as well as the understandings of health-related food messages in children. 
Factors influencing people's regular attendance to dentist  and patient expectations on emergency dental services  have also been studied in the past using qualitative means. A qualitative study was done in response to the patients' complaints regarding access to the National Health Services dental care through interviews in the UK. Specific barriers to receipt of care emerged which included patient satisfaction, cost, access, fear, and anxiety were identified and the research concluded that patients were often unaware of the nature of the service and were more focused on their immediate concerns, particularly costs and fear.  Similarly, another study tried to evaluate the perceptions in relation to oral health on people with noticeably damaged teeth. This was done using open-ended interviews and it revealed that patients who could benefit most from dental treatment can have ideas of oral health radically different from those of dentists; certain aspects of oral health remained irrelevant to them and hence health education messages passed to them went unnoticed. However, the research concluded that it can be overcome by identifying the barriers and to focus on shared power and understanding between professionals and dentists. ,
There have also been qualitative studies which have focused on the factors influencing the general dental practitioner's decision to making treatment choices  and also knowledge, attitudes, and practices of dental practitioners about systemic infections, especially HIV infection which could influence dental treatment plan. The latter study enlightened the barriers of treating such patients which include loss of other patients from practice, dealing with staff fears, increase in personal risk, and the financial burden for the practice due to increased infection control procedures and it was the first qualitative study done in this area.  Studies have also explored the content of advice provided by the General Dental Practitioners to prevent caries in young children done and this was done by interviews and revealed that there was an important variation in the approach, especially regarding fluorides, and some views expressed were not supported by evidence base. 
Various other qualitative studies have been documented in literature related to the oral health attitudes of drug users and their barriers to care,  the experiences and expectations of the families of people with Down's syndrome, and factors impacting their access to services.  Care-seeking behavior in patients suffering with toothache or pain has also been researched and it is worth mentioning that such patients actually expect more, but more informational and psychological reassurance rather than just relief from pain. 
Other wider public health issues can also be dealt with using QR like the one done in the UK on the attitudes and perceptions of the current workforce, their issues, and their potential solutions by supplementing the quantitative data by qualitative interviews and focus group discussions.  Attitudes among the stakeholders, especially the teachers, school nurses, and parents, about screening programs in schools, whether they were effective in improving the oral health,  decisions about whether to fluoridate water or not which was done in some European countries,  the oral health beliefs and practices of primary healthcare professionals,  and even dental anxiety in the waiting room of a dental office  can be studied using QR.
| Conclusion|| |
In health research, evidence gathered through QR methods is increasingly relevant to understanding the social, cultural, and economic factors affecting the health status and health care of the individual and the population as a whole. The use of QR in the field of dental public health can broaden the evidence base and practice because it allows researchers to answer important research questions that are difficult to address satisfactorily using qualitative methods alone. A better understanding of any phenomena can be achieved by the combination of both quantitative and qualitative methods. However, the uptake of QR into practice will only succeed if the findings are based on sound scientific methods and in conclusions that can be broadly understood. Rigorous norms, standards, and practices have been developed for the conduct of qualitative health research and for its inclusion in systematic reviews. Yet, these still remain less familiar to health researchers who still tend to view the quantitative studies, especially the randomized controlled trial as the research "gold standard." To discuss over the merits of qualitative over quantitative research methodologies and vice versa is futile as they are entirely different and each has a place of its own in the research armamentarium and it is much more important to ensure that the objectives of a research project undertaken are achieved for the benefit of the individual and the population.
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Roslind Preethi George
Centre for Rural and Remote Oral Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia
Source of Support: None, Conflict of Interest: None