Incorporating qualitative methodologies and fieldwork into large scale, quantitative analyses of climate health in low-income countries
Authors: Kathryn Grace, Jude Mikal
Journal: The Lancet Planetary Health (2019)

Climate can affect individual health through a number of mechanisms, including changes in food access or availability, heat stress, and drought. Each of these mechanisms are mediated by decisions that individuals, households, and communities make, and so associations between climate change and health outcomes that do not account for these pathways can disguise true effects. In a recent study examining the link between climate variables and health in Mali and Kenya, authors found compelling evidence that precipitation, temperature, and vegetation all have an effect on birthweight.1Bakhtsiyarava M Grace K Nawrotzki RJ Climate, birth weight, and agricultural livelihoods in Kenya and Mali.Am J Public Health. 2018; 108: S144-S150Crossref PubMed Scopus (22) Google Scholar A similar study examined how the climatic characteristics of a region affected growth trajectories of children under five years of age, including potentially moderating variables like transportation and health infrastructure.2Shively GE Infrastructure mitigates the sensitivity of child growth to local agriculture and rainfall in Nepal and Uganda.Proc Natl Acad Sci USA. 2017; 114: 903-908Crossref PubMed Scopus (47) Google Scholar Both studies note that although rainfall during key periods is typically associated with positive growth trajectories, quantitative associations are heterogeneous across individuals. Moreover, the associations are not fully explained after controlling for variation due to land use, food availability, infrastructure, or individual-level or household-level characteristics. Climate-health researchers have attributed the unexplained variation to a range of factors, from the adoption of modern agricultural techniques, to transportation and health infrastructure, to nutrition and care practices. The pathways proposed in quantitative climate-health studies generally come from qualitative assessments of context made by the researchers, but the directionality of those pathways is not always clear.3Amegah AK Rezza G Jaakkola JJ Temperature-related morbidity and mortality in sub-Saharan Africa: a systematic review of the empirical evidence.Environ Int. 2016; 91: 133-149Crossref PubMed Scopus (48) Google Scholar, 4Phalkey RK Aranda-Jan C Marx S Höfle B Sauerborn R Systematic review of current efforts to quantify the impacts of climate change on undernutrition.Proc Natl Acad Sci USA. 2015; 112: e4522-e4529Crossref PubMed Scopus (134) Google Scholar For instance, studies focused on investigating the association between malnutrition and climate propose that the relationship between weather conditions and child health outcomes can be partially explained by the ways a caretaker's workload changes in response to weather. In theory, children are healthier when caretakers have adequate time to care for the children.5Hampshire KR Panter-Brick C Kilpatrick K Casiday RE Saving lives, preserving livelihoods: understanding risk, decision-making and child health in a food crisis.Soc Sci Med. 2009; 68: 758-765Crossref PubMed Scopus (41) Google Scholar In practice, increased rainfall could result in greater crop yields, but create more demand for a caretaker's labor, leaving children to eat less frequently.6Jones AD Cruz Agudo Y Galway L Bentley J Pinstrup-Andersen P Heavy agricultural workloads and low crop diversity are strong barriers to improving child feeding practices in the Bolivian Andes.Soc Sci Med. 2012; 75: 1673-1684Crossref PubMed Scopus (63) Google Scholar, 7Nankumbi J Muliira JK Barriers to infant and child-feeding practices: a qualitative study of primary caregivers in rural Uganda.J Health Popul Nutr. 2015; 33: 106-116PubMed Google Scholar Equally, dry conditions and high temperatures could result in more time on heatwave mitigation efforts and less time focused on childcare. It is also possible that extreme temperatures force individuals to spend more time indoors or close to home, resulting in more time left for caretaking. This example shows how individuals can have different responses to the same extreme weather conditions, resulting in varying health outcomes. Because responses to climate are highly contextual, quantitative analyses that do not explicitly model relevant aspects of the local context can produce misleading results. To advance climate-health research and associated policies, the research community should focus on identifying, isolating, and understanding the different ways that individuals respond to climate events. Strictly quantitative analyses have provided promising insights into climate-health linkages but are limited in their ability to capture experiences relevant to local contexts and cultures.8Nelson DM Who counts? The mathematics of death and life after genocide. Duke University Press, Durham, NC, USA2015Crossref Google Scholar To capture variability in these dynamics, attention must be paid to local norms surrounding the ways that people interact and spend their time. Local stakeholders (all individuals in an area, including those living in the communities of interest as well as local policymakers, health workers, and educators) manage complex risks in everyday practice, and using available resources and risk mitigation strategies can provide valuable insights into research. These local stakeholders can provide unique perspectives on a range of highly relevant behavioural responses, including those related to time management, food rationing, caretaking practices, and other strategies used to reduce the adverse effects of climate change. Accessing and chronicling this information allows researchers and policy makers to better determine the ways a household and community respond to aberrant climate events. Unfortunately, standard demographic and health surveys used for climate-health research rarely capture local norms surrounding the ways that people interact. To remedy this, we suggest augmenting climate-health research with qualitative methodologies and field work at every stage, to advance scientific and policy understanding of the effects of climate change on health. Three areas of qualitative research can be used to inform and augment research findings: context, perspectives, and policy. To promote contextual understanding, researchers could focus on a particular phenomenon or process of interest and find a systematic way to observe the way that a process unfolds. For example, Shively2Shively GE Infrastructure mitigates the sensitivity of child growth to local agriculture and rainfall in Nepal and Uganda.Proc Natl Acad Sci USA. 2017; 114: 903-908Crossref PubMed Scopus (47) Google Scholar found that rainfall at key developmental junctures affected growth trajectories in children under five years of age. Making specific policy recommendations based on these findings is difficult, but contextual studies might focus on how care practices are likely to be affected by rainfall at different ages, including how increases in rainfall may affect agricultural yields and demands for labour. Such studies of context involve techniques like ethnographies and broader-level ethnographic methods (including living in and engaging with communities, languages, and cultures), and start with the assumption that there are well-thought-out adaptive processes being implemented by members of the community. Context is not an attempt to understand everything about a country or culture, but rather an attempt to develop a culturally informed understanding of the object under study, including climate and food production, or climate and child care. Researchers observe the ways in which those processes unfold pre-intervention, asking questions of local informants, generally guided by or facilitated by local research associates. Data is generated via field notes kept by researchers. Although contextual studies might include talking with local stakeholders, studying perspectives would generally include interviews or focus group discussions. These interviews could then be used to provide additional information on the mechanisms, motivations, or cultural values underpinning an observation of interest. In the case of birth seasonality, for example, studies of perspectives could use focus group interviews to establish if women feel capable of choosing the time of year they become pregnant, or how important seasonal hunger patterns are in the choice to exclusively breast feed and in the duration of breastfeeding behaviour.9Grace K Considering climate in studies of fertility and reproductive health in poor countries.Nat Clim Chang. 2017; 7: 479-485Crossref PubMed Scopus (31) Google Scholar This method assumes that stakeholders make decisions and act in ways that reflect a strategic calculation of risks and benefits, and so the processes underpinning those calculations can be better understood by directly asking about their motivations and behaviours. Perspectives can be gained through conversations with various stakeholders and the list of questions can be rigid or flexible. In more exploratory cases it is generally best practice to use focus groups with a semi-structured protocol, because participants can discuss the topic together and come to a consensus. Flexible lists of questions allow researchers to ask about contradictions or rich points as they emerge.10Agar MH Ethnography: an overview.Subst Use Misuse. 1997; 32: 1155-1173Crossref PubMed Scopus (29) Google Scholar Interviews are often recorded and transcribed, and a qualitative researcher will use those written transcripts to look for themes that help provide insight into mechanisms, motivations, or values. Policy research can include a variety of tools, but is often based on conversations with policy makers or other officials entrusted with decision making and resource brokering. Interviews are useful in gaining insight into the history or justification of a policy or in understanding previous efforts to remedy a particular problem. Lists of questions can be rigid or flexible, and interviews are often transcribed and redacted to serve as data for later publication. Policy research can also be expanded to include archival research that consists of legal proceedings, newspapers, and other documents that might provide additional insight into the broader political context. Analysis of policy data looks similar to analysis of interview transcripts. Qualitative researchers might begin by looking at all instances of the word or phrase heatwaves or climate change in local media. Next, they might use those documents to identify elements of a pre-existing theory, or answer questions regarding public perceptions of heatwaves or climate change and how those have evolved over time. In conclusion, qualitative approaches can be used to design empirical studies that capture culturally informed perspectives by willingly participating stakeholders. Engagement with local stakeholders should begin in the very early stages of research design, and should be revisited throughout the duration of the study. Interactions with stakeholders can be systematic, scientific, and documented for the purposes of reliability and reproducibility, and importantly, should be published to facilitate access by the scientific community. Bringing everyday lived experiences of individuals into quantitative climate-change research can help ensure that science and policy reflects the strategies that local people are already using to protect their health, and addresses the concerns and challenges facing those who are most vulnerable. We declare no competing interests.