Editorial
International Journal of Qualitative Methods
Methods in the Time of COVID-19: The
Vital Role of Qualitative Inquiries
Michelle Teti1, Enid Schatz1, and Linda Liebenberg2
COVID-19 is not just a medical pandemic; it is a social event
that is disrupting our social order. As Leach and colleagues
(2020) noted in a recent online essay:
The dynamics of the virus, infection and immunity, not to mention
on-going efforts to revise and improve clinical care, and endeavors
to develop medical treatments and vaccines, are a critical part of
the unfolding story. So, too, are peoples’ social responses to the
disease and interactions with each other. COVID-19 is revealing,
reinforcing, and catalyzing new social and cultural relations; lay-
ing bare inequalities and anxieties, discrimination and division; but
also galvanizing solidarities and collective action.
Qualitative inquiries are our best method for capturing
social responses to this pandemic. As has been shown with
other epidemics and health, these methods allow us to capture
and understand how people make meaning and sense of health
and illness (Schatz et al., 2013; Teti et al., 2015). In this edi-
torial, we reiterate the value of qualitative methods to help
explain, address, and plan for disease outbreaks and health
emergencies.
In December 2019, COVID-19 was recognized in Wuhan,
China (Wang et al., 2020). Since then, the virus has caused
serious illness, death, and social disruption around the world.
The scope of the outbreak is rapidly evolving and ever chang-
ing. At the time of this writing, there were nearly 800,000
confirmed cases of COVID-19 and almost 40,000 deaths
(Johns Hopkins University and Medicine [JHUM], 2020). As
of the end of March, the United States leads the world in case
counts. Neither a vaccine nor a cure exists—and in many
places, testing remains limited. Thus, in most places, public
health officials have moved on to mitigation by instructing
everyone to engage in hand hygiene, social distancing, and
quarantine to protect themselves and others.
Outbreaks like COVID-19 draw attention to the importance
of epidemiology, the study of distribution and determinants of
health and illness among specified populations (Last, 1988).
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Epidemiology is predominantly a quantitative science in which
researchers work to define an outbreak, find cases, generate
rates of illness, and develop and evaluate hypotheses about the
causes of illness and how it is spread. Epidemiological data
have resulted in information about who is affected by
COIVD-19, how it works, and who survives or dies from the
illness (JHUM, 2020). Inevitably, however, quantitative epide-
miological models miss the social implications of disease.
They are not well suited to capture the reasons for people’s
behavior, the social interactions, or the ways people make
sense of what is happening around them (Leach et al., 2020).
Qualitative methods are valuable alongside traditional quanti-
tative epidemiological methods given their open-ended nature
and focus not just on “what” but on “how.” Interviews, group
discussions, and observations explore and embrace different
viewpoints, meaning, and motivations. They can help explain
the gap between assumptions in epidemiological models and
social realities as well as why certain outbreak interventions
work and others fail (Leach et al., 2020; Wolff et al., 2018).
Although not always as visible as the case numbers during
an epidemic, a large body of evidence supports the value of
qualitative methods in epidemic and pandemic research. In
fact, leading global health agencies like the World Health
Organization and the Centers for Disease Control and Preven-
tion recommend using qualitative methods in epidemiologic
investigations (Wolff et al., 2018). In a review of the use of
qualitative methods to study health emergencies, Johnson and
Vindrola-Padros (2017) identified 22 examples where qualita-
tive methods were used to assess causes, prevention strategies
1
Department of Public Health, University of Missouri, Columbia, MO, USA
2
Dalhousie University, Halifax, Nova Scotia, Canada
Corresponding Author:
Michelle Teti, Department of Public Health, University of Missouri, Columbia,
MO, USA.
Email: tetim@health.missouri.edu
2 International Journal of Qualitative Methods
and solutions, health needs, and health systems use during
disease outbreaks (e.g., flu, Ebola Virus Disease [EVD],
malaria) and natural disasters (e.g., hurricane, tsunami). Simi-
larly, Crawford et al. (2016) explored qualitative lessons from
recent epidemics like SARS, H1N1, and EVD identifying
issues to be improved for future pandemics. They highlight
how cultural and political confidence in institutions can bolster
responses, whereas clashes may undermine confidence in these
institutions. In fact, during the EVD outbreak of 2014–2016,
anthropologists were critical to providing qualitative insight,
analysis, and advice about how to engage with the social, cul-
tural, and political aspects of the epidemic (e.g., caregiving,
burial rituals) to build effective interventions (Institute of
Development Studies and London School of Hygiene & Tro-
pical Medicine, 2018). Their work is described in The Epi-
demic Response Anthropology Platform (Institute of
Development Studies and London School of Hygiene & Tro-
pical Medicine, 2018). Similarly, collections of qualitative data
describe HIV (Geter Fugerson et al., 2019), injection drug use
(Guise et al., 2017), smoking (Flemming et al., 2015), and other
chronic illnesses from the perspectives of people living with
and/or attempting to successfully address or treat those health
challenges. These contributions are critical to understanding
both people’s lived experiences of disease and the ways that
individuals and communities make sense of disease endemic to
their social worlds. Below, we highlight five essential contri-
butions of qualitative methods during epidemics.
1. People’s health behaviors do not always fit neatly into
epidemiologic models. This is even true in “normal
times.” For instance, although epidemiological research
links smoking with lung cancer, qualitative research has
shown that some youth continue to smoke because they
believe the disease is not a high risk for them (Hefler &
Chapman, 2015). Likewise, research links unprotected
sex to sexually transmitted infections. In interviews
with poor, urban women at risk of HIV, however, it
became apparent that condom-less sex was key for
women to maintain denial of cheating in their relation-
ships, preserve their belief in their ability to judge part-
ners, and maintain their self-esteem (Mojola, 2014;
Sobo, 1995). These examples highlight that causal links
between behaviors and risks are not always sufficient
for people to enact recommended preventative beha-
viors. Currently, health leaders are advising people to
use social distancing and quarantine to limit COVID-19
exposures. Yet qualitative studies show that many dif-
ferent complex psychological, cultural, and social fac-
tors limit compliance. These include mistrust in
government and a history of use or perception of use
of quarantine as a social control mechanism (Tulloch &
Ripoll, 2020).
2. Vulnerable populations. Vulnerabilities to disease are
not just biological but social. Qualitative methods can
shed light on the needs of particular marginalized
groups during health crises and infectious or chronic
illness epidemics. From its inception, for example,
HIV/AIDS-affected communities and groups of people
that were already vulnerable to stigma—like gay men,
people living in poverty, injection drug users, and sex
workers. Qualitative inquiries have played a key role in
revealing that the stigma of HIV in addition to preexist-
ing social stigmas has played a major role in limiting
access to HIV information, testing, and treatment
(Chambers et al., 2015). Regarding the current
COVID-19 pandemic, qualitative methods can shed
light on ways the virus can hurt vulnerable people like
poor families who cannot eat without school meals
(Associated Press, 2020), incarcerated populations who
are not able to socially distance themselves (Kindy,
2020), and communities where population density is
extreme but access to sanitation and food is low, such
as slums (Sur & Mitra, 2020). A student in Kenya
recently discussed the challenges he and other Kenyans
had taking COVID-19 seriously, amid other preexisting
vulnerabilities:
Dear coronavirus, welcome to Kenya . . . here, we don’t die of flu.
Don’t be surprised if you fail to succeed. Everything fails in Kenya.
Kenya is not excited to host coronavirus. The locusts, the biggest
infestation in 75 years, got here first. We also cannot afford to pay
you too much attention because we are really, really broke. We are
more likely to die of a cholera attack than to be killed by you. For
us, every day is a run to escape from death. We are the walking
dead. (Peralta, 2020)
His sentiments underscore the complexities that vulnerable
people face during epidemics and the need to capture that
complexity to understand the scope and impact of an outbreak.
3. Unexpected consequence or surprising outcomes. Qua-
litative methods are well suited to exploring the reasons
that epidemic solutions and strategies work or fail or
uncovering unexpected consequences of actions taken
during epidemics. In a qualitative exploration of flu
behavior during the 2009 H1N1 flu outbreak, Flowers
and colleagues (2016) found that the majority of work
surrounding hygiene, personal protection, and caregiv-
ing during the outbreak collided with gender inequities
and unfairly burdened women, worsening gender-based
inequities and women’s vulnerabilities. Via focus
groups, interviews, and observations with communities
after the EVD outbreak in Sierra Leone, qualitative
researchers found that quarantine put people in danger
of starvation given preexisting food insecurities (Kod-
ish et al., 2019). Similarly, during EVD, bushmeat bans
contradicted people’s experiences of safely consuming
wild meat, and the criminalization of bushmeat wor-
sened distrust between communities and outbreak
workers (Bonwitt et al., 2018). It is early in the
COVID-19 pandemic to understand all of the unex-
pected outcomes of public health efforts, but early fears
Editorial
about the virus in the United States, for example, have
contributed to shortages of masks and sanitizer for med-
ical staff who need these resources to care safely for
others (Nyugen, 2020). In addition, fears related to the
origins of COVID-19 have led to increases in discrim-
ination against Asian communities in the United States
(Phillips, 2020). Similarly, the expansion of preventa-
tive measures is having a profound impact on social
structures and social function. Within these considera-
tions are concerns, for example, of the impact of social
distancing on mental health as well as effectively sup-
porting individuals isolated with abusive partners.
These issues need careful qualitative study, not just
journalistic reporting.
4. Medical response experiences. In previous outbreaks
similar in nature to COVID-19 (e.g., H1N1, SARS,
EVD), qualitative approaches have been key accompa-
niments to traditional quantitative outbreak investiga-
tions in highlighting the needs of medical and other first
responders and their interactions with affected commu-
nities. Qualitative studies during the EVD outbreaks in
Sierra Leone, Guinea, and Liberia uncovered many
challenges and lessons learned. These included peoples’
fears of calling the Ebola help line because their loved
ones would be sent away (Yamanis et al., 2016), impas-
sable roads causing health workers to walk up to 8 hr a
day to reach remote communities (Summers et al.,
2014), lack of standard procedures to clean ambulance
and burial vehicles increasing infection spread (Path-
manathan et al., 2014), and fears that health care work-
ers were injecting patients with EVD (Dynes et al.,
2015). Even though we are early in the COVID-19 epi-
demic, qualitative reports from medical responders are
uncovering challenges like limited testing availability,
difficulty identifying persons with COVID-19 based on
signs and symptoms alone, and lack of protective gear
(McMichael et al., 2020). One can only surmise that
fears similar to those of the EVD pandemic exist in the
public as well, such as reluctance to report illness given
fears of social isolation and limited treatment options.
In the United States, lack of universal health care and
access to care are additional barriers to reporting cases
(National Center for Health Statistics, 2018).
5. Getting community buy-in. Public health solutions and
tools are only effective if people use them. In response
to the epidemic of injection drug use in the United
States, for example, public health officials implemented
safe needle exchange programs to support the use of
clean needles, a seemingly logical way to avoid spread-
ing illness. Bourgois’s ethnographic immersion into the
lives of self-identified heroin addicts, however, showed
that the logistics of addicts’ income-generating strate-
gies, their desperate need to overcome dope sickness,
and the moral economy of sharing resources among
addicts resulted in daily sharing of needles despite the
availability of clean supplies. Thus, a solution that
3
public health experts considered as automatic did not
work for the most at-risk drug users (Bourgois, 1998).
Qualitative methods can help uncover assumptions
underlying public health plans, signal the need to plan
with communities, and engage communities in group
and individual discussions. For example, community
forums in response to SARS and H1N1 outbreaks in
South Australia identified that quarantine would be
more successful if community members had effective
financial and psychological support plans to manage the
quarantine (Braunack-Mayer et al., 2010). Qualitative
methods are well suited to explore how people react to
the uncertainty and disconnection that accompany
methods like quarantine. Pandemic planning with First
Nations communities in Ontario, Canada, resulted in
refined plans for how medicines and supplies could be
transported, received, and stored in remote locations
(Charania & Tsuji, 2012). Similarly, a key lesson from
the West African EVD outbreak was how crucial com-
munity engagement is for a successful outbreak
response. Despite failed health care systems and over-
run hospitals, communities were resilient and flexible.
They created their own safe burial processes and ways
to isolate and care safely for the sick (Abramowitz et al.,
2015). The lack of cooperation with quarantine and
social distancing in the United States, for instance,
highlights the importance of community buy-in, among
other things, in achieving effective containment of
COVID-19 (Madani, 2020). Without the type of results
that qualitative methods can yield about effective social
response, the successful management of this outbreak
may very well remain elusive.
Qualitative methods can play a pivotal role in understanding
epidemics like COVID-19, the people involved in them, and
effective solutions and strategies. Despite the challenges posed
by this current crisis, it is precisely at times like these that we
should celebrate and make use of these methods. Qualitative
methods are positioned to explore the plurality of expertise and
diversity of perspectives necessary to understand fully the
COVID-19 pandemic as it unfolds (Leach et al., 2020). Quali-
tative methods can give insight into the current situation as it
evolves and lessons to bring to bear on future epidemics and
how to effectively manage them.
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