The value of qualitative research methods in suicide prevention/suicidal behaviour research

By Isabela Troya.

Suicide and suicidal behaviour are complex and multifactorial, influenced by a range of different determinants. Despite the complexity of suicidal behaviour, the approach taken within the field of suicidology in research has been mostly dominated by a single research design: quantitative methods. Hjelmeland and Knizek [1] have already documented the lack of qualitative research within suicidology [1], advocating for the need of qualitative research within the field. Nearly a decade after Hjelmeland and Knizek’s [1] article, the number of studies conducted using qualitative research designs has indeed increased, although perhaps not as much as expected/hoped to reach a balance. I would like to invite fellow early-career researchers to consider the potential of qualitative research by presenting 3 (of many more) advantages given when using this research design when attempting to advance knowledge in the field of suicidology.

1. It’s not just about numbers and statistical significance

Yes, we appreciate the importance of getting that p<0.05 and those narrow confidence intervals. Indeed, quantitative research is needed within the field of suicidology, as it allows us to: (a) estimate the prevalence of suicidal behaviour amongst different groups (epidemiological studies), or (b) calculate whether an intervention for reducing suicidal behaviour was effective or not (RCT’s), or (c) estimate risk factors for suicidal behaviour amongst certain groups, amongst others.  But we are more than just numbers, and quantitative research can be limited to describing factors, rather than explaining or understanding. Take the hypothetical example of an RCT aiming to reduce suicidal behaviour amongst young teenage girls through the use of an 8-week mobile app. Despite the intervention proving to be significant reducing mean scores of suicidal ideation amongst the group as a whole, sub-group analysis showed teenage girls from ethnic minorities were not adhering to the intervention and resulting in no reduction amongst this sub-group. Qualitative research would be of great use, given that a focus group or individual interviews with teenage girls from ethnic minorities could help understand why this group of teenage girls were not adhering to the intervention. Through the use of qualitative methods, emerging themes from the group of teenage girls could help researchers understand the lack of adherence was due to lack of mobile data access, stigma amongst peers and family, or non-accessible or identifiable app design for this teenage group. These results could elucidate researchers in creating a more accessible intervention for teenage girls from ethnic minorities. Although the above mentioned is a hypothetical example, other fields within healthcare research have benefited from using qualitative methods after evaluating the lack of treatment adherence amongst certain sub-groups [2].

2. Generating hypothesis

Being exploratory in nature, qualitative methods allow the generation of hypothesis. Qualitative methods allow researchers to gain an understanding of a certain phenomenon, including motivations, opinions, or attitudes of participants. Within the field of suicidology, this has been of great importance, given that researchers have gained an understanding of suicidal behaviour through the use of qualitative research in generating hypothesis. An example of this can be given with ethnography. Ethnography is a qualitative research method which gives researchers an in-depth understanding of the social interactions, behaviours, and perceptions that occur within groups and communities [3]. In ethnographic research, researchers observe the interactions of a certain group, as well as their behaviour and perceptions. But how is this applicable to the generation of hypothesis within suicidology? DiStefano [4] gives an example of ethnography used to understand suicidality amongst sexual minorities in Japan. Through observation of LGBT groups, DiStefano [4] was able to understand the specific factors leading to suicidality amongst this group in Japan. This allowed DiStefano [4] to generate an initial hypothesis regarding motivations and influencing factors for suicidal behaviour amongst LGBT groups in Japan, a group under-researched in the country when it came to suicidal behaviour. DiStefano’s [4] hypothesis could be tested or compared with other LGBT groups, in order to see whether his research is applicable to others.

3. Broadening our understanding of suicidal behaviour through

Traditionally, qualitative research is associated with interview studies or focus groups. Despite the predominance and importance of these methods, there are alternative methods which can be used when conducting qualitative research, many of which are still under-used despite their potential. In the field of suicidology, making use of alternative qualitative methods are fundamental to gaining insight into the processes and thinking behind suicidal behaviour and ideation. Not everyone experiencing suicidal thoughts or behaviour will be ready or willing to share their views through traditional methods such as interviews or discussion. This is why alternative methods in qualitative research are of great use to gain an alternative in-depth understanding of people experiencing suicidal behaviour and/or thoughts. Analysis of diaries, media reporting, previously mentioned ethnography, visual representations (art, photography), are other qualitative research methods that allow researchers to gain an in-depth perspective of participants with suicidal behaviour. Offering a unique perspective to the suicidal mind, these qualitative methods give researchers the opportunity to explore the different elements behind suicidal behaviour which would not be accessible with traditional research methods. Sanger & Veach [5] provide an example of the unique perspective gained by making use of qualitative research when analysing suicide notes of people who died by suicide. Through the analysis of suicide notes, Sanger & Veach [5] were able to identify thoughts, influencing factors, and behaviours considered prior individuals dying of suicide. For the proportion of people who die by suicide without presenting any of the major risk factors for suicide, this study proved essential in providing insight and understanding of the suicidal mind.

Qualitative research, when conducted correctly, gives researchers the opportunity to enhance the understanding of their research, giving a more in-depth perspective. I have summarised 3 main points of why I believe qualitative research is of great value to early and mid-career researchers researching suicidal behaviour. Whether conducted alongside quantitative research (mixed-methods), stand-alone, or to inform quantitative research designs, qualitative methods allow researchers to gain an in-depth understanding of the different aspects of suicidal behaviour. Therefore, I invite fellow early and mid-career researchers in suicidology, to consider the benefits of using qualitative methods, and look for opportunities of learning and applying this research design in their future research.

Note:
[1] Less than 3% of articles published in the main journals for suicidology (Crisis, Suicide and Life-Threatening Behavior, and Arichives of Suicide Research) made use of qualitative methods (Hjemeland & Knizek, 2010).

References

1. Hjelmeland, H., & Knizek, B. L. (2010). Why we need qualitative research in suicidology. Suicide and Life-Threatening Behavior, 40(1), 74-80.
2. Morrison, Z., Douglas, A., Bhopal, R., & Sheikh, A. (2014). Understanding experiences of participating in a weight loss lifestyle intervention trial: a qualitative evaluation of South Asians at high risk of diabetes. BMJ open, 4(6), e004736.
3. Reeves, S., Kuper, A., & Hodges, B. D. (2008). Qualitative research methodologies: ethnography. Bmj, 337, a1020.
4. DiStefano, A. S. (2008). Suicidality and self-harm among sexual minorities in Japan. Qualitative Health Research, 18(10), 1429-1441.
5. Sanger, S., & Veach, P. M. (2008). The interpersonal nature of suicide: A qualitative investigation of suicide notes. Archives of Suicide Research, 12(4), 352-365.

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Isabela Troya (@IsabelaTroya) is a PhD student at the Institute for Primary Care and Health Sciences at Keele University (m.i.troya.bermeo@keele.ac.uk) and Clinical Psychologist from Ecuador.

*Cover Photo by Aaron Burden on Unsplash.