Abstract
Qualitative researchers have a rich tradition of bringing voice to those who are experiencing inequities; uncovering the lived realities of poverty, social exclusion and repressive power; and examining concepts of vulnerability, contextual influences and community engagement. But this learning has not yet been infused adequately into the realm of community health intervention research. New opportunities are emerging to enhance this cross-walk and leadership from within the qualitative research community is essential.
There are two key indications that community health intervention research is at an important crossroads for change. First, growing health inequities have led to many calls for action on social and structural determinants of health. Research aimed at understanding how these determinants influence health has been a necessary but insufficient response. Taking action involves multi-level strategies in health and other sectors and the use of socio-ecological and participatory models. A more balanced research agenda requires investments in areas such as realist reviews, mixed methods research designs and implementation science. The latter realm of scholarship tackles questions including how do interventions work, for whom, and under what conditions? Implementation science turns the lens of inquiry onto how interventions interact with and are shaped by the context in which they unfold. It requires a deep understanding of contemporary and historical contexts (e.g. changing gender and power roles in society), an illumination of critical pathways that explain how interventions might exacerbate or mitigate inequities, an explicit identification of one's ethical perspective and genuine stakeholder engagement.
A second indication that there is readiness for change is the increasing recognition that diverse epistemological traditions and methodological approaches are required to address tenacious health inequities. Leading scientists are describing the need to become familiar with and build on research undertaken in other disciplinary fields. Nancy Krieger, in her recently published book Epidemiology and the People's Health (2011), offered some self-critique, indicating that she only became conversant with the political ecology literature in 2007, a decade after she started to “substantially contribute to the conceptualization of ecosocial theory” (p. 228). Wallerstein, Yen and Syme (2011), consider the gains that would be achieved through “reciprocal learning” between social epidemiologists and community interventionists. Thomas and colleagues (2011) have argued the need for a fourth generation of disparities research to achieve health equity. This would build on three earlier generations of health disparities research (detecting, understanding and providing solutions), which have been more steeped in quantitative traditions. Central to the fourth generation is “transformational thinking beyond our standard research paradigms” (p. 406). It is characterized by several core elements including: utilizing public health critical praxis as a conceptual framework, addressing structural determinants of health through comprehensive multi-level interventions, and ensuring explicit attention to self-reflection by researchers since we are all a product of the subtleties of racism which “plays out in the ordinariness of daily life” (p. 407). These serve as illustrative examples of a changing discourse, which seems less inclined to pit quantitative and qualitative traditions against each other and more likely to integrate alternative methodological approaches while respecting different paradigmatic views.
Successfully responding to these opportunities for change will require the efforts of both research funding agencies and researchers, creating what Fran Baum (2007) refers to as the “nutcracker effect”. Research funding agencies must develop requests for applications from interdisciplinary teams, imploring the use of diverse research methods and supporting a programmatic approach that provides for integrated learning among team members. Peer reviewers must reflect the multidisciplinary composition of applicants. Furthermore, the peer review process will need to be supportive of risk and innovation, allowing for the paradigmatic and methodological tensions that will necessarily exist within research of this type.
Research agencies cannot achieve this alone. Changes need to come from the grassroots of academia as well. A strong response to new funding opportunities is required from researchers of all traditions. This involves taking risks, working beyond one's disciplinary comfort boundaries, and working within academic and other organizations to encourage the establishment of incentive structures to support this type of research.
It is through a groundswell of qualitative researchers leading work in this area and teaming up with community health interventionists that a more rapid and dramatic shift in health inequities can be realized. Taking action on social and structural determinants of health requires the very best of a wide range of traditions. Thus, it is critical that qualitative researchers create and act on a vision of how their work can shape the next generation of action-oriented community health research to tackle health inequities.