The shortcoming of KAP studies

As yet, true interdisciplinary research in One Health is rather rare. So-called socioeconomic or sociocultural studies on zoonoses are largely questionnaire-based and can include knowledge, attitude, and practise. Short KAP studies. In One Health, they are often led by veterinarians with no further training in qualitative methods. KAP studies are more generally used in cross-sectional surveys. The reason for this is that they are less time consuming and less costly than in depth qualitative studies. Apparent advantages, it seems. However, KAP studies can be misleading. They can give us the mistaken impression that we can easily collect data on health seeking practises and that these will be usable for programme planning. Reality is more complex. Let us have a look at an example.

Tuberculosis, as you might know, can also be zoonotic. Our example comes from remote Mauritania, where access to information and diagnosis is very limited. A Mauritanian sociologist found that TB was part of different illness concepts according to different causes and different stages of the disease. It was perceived either as due to spiritual or biomedical causes and it could also be stigmatising depending on the illness assigned. Initial diagnosis was usually made by people in the local vicinity of the patient, such as a faith healer and or traditional healers. But could also be made by community members. The assigned local illness name directed the patient then to where first to ask for health care.

Obviously, planning for TB information campaigns in Mauritania needs to address these multi-layered perceptions of the same disease to have any impact. Many KAP studies include open-ended questions in a questionnaire. If you, however, think of a rural setting, questionnaires are a rather unnatural method for collecting information. How could you capture insights on dynamics and changes in the society you are interested in? I have photographed the close surroundings of academic colleagues in East Africa and Southeast Asia. Not visible on these photos are, for example, the smartphones and charging equipment they use. Thus, these pictures hide important information which might well influence essential concepts. Similarly, with KAP studies, you might record what people know about practises.

But with these sort of questionnaires, it might be difficult to get information about the actual day-to-day practises and how they explain them. KAP studies most often focus on biomedical explanations and neglect other types of knowledge. Thus, they disregard culture specific notions about illness or knowledge that relates to health systems, as seen in the example of tuberculosis in Mauritania. In the slaughterhouse study, the religious knowledge of the abbatoir workers was termed beliefs. However, such beliefs may the key to appropriate behaviour and treatment seeking practises. When confronted with a survey question, people tend to give answers they believe to be correct or which they think to be generally acceptable and appreciated by the interviewer. The survey interview context can influence the answer.

This might, for instance, be the case when it is about drugs or if there are any expectations. This is also the case when the interviewee feels self-conscious about his or her home and would like to make a good impression. Vice versa, the question formulation can be manipulative towards a favourable answer. Therefore, attitudes interlinked with the person’s knowledge, beliefs, emotions, values are not as easily captured with a questionnaire. Finally, we all know what people say and what they really do are not necessarily the same. If my doctor asks me about any bad health habits I have, my answer might not be very accurate and rather on the optimistic side.

I would also surely state that I have sufficient information to judge my health risks. If a health professional would then observe me closely during the next day, they would maybe come to a different conclusion and would likely be disappointed. Knowledge is only one of many factors that influence how people seek treatment or how they behave when confronted with illnesses. Questions about practises are rather hypothetical. Nevertheless, health programmes are still often based on the assumption that there is a direct relationship between knowledge and behaviour. To change behaviour, which is the hardest field in health, programmes need to address multiple factors ranging from sociocultural to environmental and economical factors.

Social scientists I know need many months or even years to analyse their data. They need time in order to condense what they have collected and to make sense out of it. The data first needs to be sorted and aligned with objectives and research questions. Then they are critically reviewed. Where do these data differ from and where they confirm theories? How may the empirical facts be listed in terms of their scientific, practical, and political relevance. As a last point, I think that we need to go beyond close-ended questions in order to understand any health problem. The more we know, the better we can reasonably analyse the answer to these sorts of questions. But we need to embed them in broader facts.

I feel that it is important to acknowledge the limitations of rapid appraisals. The best approach for you would be to seek true and meaningful collaborations with social scientists from the beginning of your research. You need also to ensure that there are institutional arrangements so that all disciplines have profound, disciplinary backstopping.