Humanizing quantitative data: A Q&A with Chloé Roubert and Micki Semler

This week, the foundation published its annual Goalkeepers Report, focusing on the impact of and response to COVID-19. As usual, there is plenty of quantitative data in the report: Charts, graphs, and models. This year, however, we also worked hard to bring in qualitative data that would help readers better understand people’s lived experience. We worked closely with a team helping the foundation on a two-year interdisciplinary project called Pathways, which is designed to generate insights about what vulnerability really means for women in two states in India and in Kenya. Chloé Roubert and Micki Semler lead the Kenya work highlighted in the report.

Chloé:  I come at it from the perspective of anthropology, which helps me better understand the messy complexity of human life. The method of ethnography is a way of going deeper into how human beings make meaning in their lives. People draw on social life—social and cultural norms, ideologies, myths, religion, gender, language, and more—to create mental models to organize and understand their lives. So, to design interventions that successfully improve health, we need to account for the mental models people create around health.

Micki:  The social science perspective means understanding a person’s behavior in context. In global health, we're often talking about starting certain behaviors, stopping certain behaviors, maintaining adherence to things, but in order to be effective at doing that at scale, we have to first understand where people are. Once we know that, we can co-design solutions to meet them where they are. Without being people-centric about someone's individual experience first, we're going to miss what their priorities are.

Chloé:  I come at it from the perspective of anthropology, which helps me better understand the messy complexity of human life. The method of ethnography is a way of going deeper into how human beings make meaning in their lives. People draw on social life—social and cultural norms, ideologies, myths, religion, gender, language, and more—to create mental models to organize and understand their lives. So, to design interventions that successfully improve health, we need to account for the mental models people create around health.

Micki:  The social science perspective means understanding a person’s behavior in context. In global health, we're often talking about starting certain behaviors, stopping certain behaviors, maintaining adherence to things, but in order to be effective at doing that at scale, we have to first understand where people are. Once we know that, we can co-design solutions to meet them where they are. Without being people-centric about someone's individual experience first, we're going to miss what their priorities are.

Micki:  From the very beginning, we engaged local researchers and translators to support us in thinking through how to engage with families. When we paired up, each researcher and translator would be a team in the field, but then when the day finished, it was important to us that we debriefed together and interrogated our different understandings of what we had learned that day. By working with local researchers and translators, we were able to build on what we were learning in the interviews with very localized and contextual understandings of some really complicated practices like female genital mutilation or polygamous marriage.

Chloé:  The logistics can be complicated when you go into the field. You want to get a strong cross section of people to talk to so you're looking across age, gender, and health experiences to find a broad mix. You are also triangulating what you hear from your interviews and conversations with local researchers and translators with the literature review that we did before we designed the research. One thing that is really important is that the ethnographic interview is designed to empower the women and men we speak with to drive the conversation toward the topics and themes that are most important to them. For example, we designed a set of cards for the people we were interviewing to respond to, and we'd start the interview by asking them to choose an image representing what they felt was most critical to talk about. It might look a bit messier than a standard question, answer, question, answer of a traditional survey, but it creates more genuine exchanges.

Chloé:  I think it’s very interesting looking at very macro level shifts and then how they manifest at a micro level.

Micki:  Yeah. Think about the intergenerational passing of land from fathers to sons. As the plots get smaller, there’s less economic opportunity, and that can then push men to get jobs in casual labor. But during times like COVID-19 when casual labor is harder to find, that puts more economic strain on the household. And with more economic strain, there tends to be increases in stress and higher rates of violence and substance use. At the end of the day, this impacts health. So, our aim is trying to bridge changes that have been happening for generations, with things like land tenure, down to how someone accesses health care in a pandemic. It seems like a very long process, but in reality it is all woven together.  

Chloé:  Another aspect that struck us is related to how in global health, we want to create a better world. Obviously, we all do. But what is a better world? And when we would ask women and men, "What do you hope for?" a lot of times the answer was, "I want to become a model, or an actor, or an influencer on Instagram.” In many living rooms, we found posters of McMansions that literally say, "If you pray dreams come true." There would be a McMansion, in the back of a perfect white family with a man and a woman, a boy and a girl, sitting on a lawn with a red Ferrari in the driveway; basically the American suburban dream. And what’s so interesting is that a lot of the inequality in the world is because of this dream. It becomes very complicated to try to tease out who decides what a good future looks like.

Chloé:  Micki’s so empathetic. I think it's her social work background, and she's kept in touch with a lot of these women. And I think, very genuinely, she was asking, “How do we help?” And not from a condescending perspective, but just knowing how hard this was going to be. She got us to map out a research plan that would be beneficial for Pathways and to support the families. Also when we were developing this, in the early days of COVID-19, it felt like everything needed to be rethought—including how to do research—and that was something we were excited to iterate and do with our collaborators in Kenya. 

Micki:  That was nice, Chlo! I think from a research perspective, we've been asking, families, “Who would you call on during times of crisis?”—because this is a large part of understanding vulnerability. But when COVID-19 hit, there actually was a real-time crisis. So, in terms of more accurately understanding human behavior and decision-making, it was an opportunity. I really think that given the instability, fears, and unknowns of the situation, a lot of the women we spoke to appreciated the interview as a way of expressing themselves. Many women don’t really have an avenue to advocate for their needs and don’t believe that their voices will be heard.

Micki:  Well, the short answer is yes but we're not exactly sure how at the moment. It is incredibly important to us that the COVID-19 research be useful for inspiring action. We recently had a couple of workshops with Gates Foundation teams where we identified areas of opportunity based on the work they have going right now. The final step will be trying to understand what makes the most sense based on feedback from local stakeholders in Kenya. We're going to wait to see, at a local level, what's being done, what isn't being done, and what the priorities are there.

Chloé:  I think at the beginning of the pandemic, our thinking was, we need to show what the reality looks like so that the health message or interventions can be implemented properly. And very early-on in our work, it became clear that while people are nervous about COVID-19, this is a socioeconomic experience. So, the idea that, “If humans understand it as a health emergency, they will do the right thing,” would not work. Now that’s very clear to everyone, but when our report initially came out, it wasn’t fully understood that way. So, I think if we can continue to communicate what communities want and need, we will impact decision-making.

Micki:  For me, one of the most effective ways to deal with feeling overwhelmed with emotion is translating it into action. And that was made possible by the local researchers. There were a few times after interviews when the situation within someone's home appeared dangerous or highly risky, and we followed up with a trained community health worker to make sure that she would return to the family’s home in the near future. After gaining an even deeper connection to their own communities through work with the Pathways project, several of our local research teammates have started their own social service and advocacy initiatives. I cannot tell you how truly inspired and motivated that makes me.

Chloé:  There were some stories that were so overwhelming. The interview with Faith, who’s in the Goalkeepers report, was very emotional. It was very intense. It was too difficult not to tear up with her. What is difficult too is that you don't want to commodify trauma or play into the slum tourism idea: "Ooh, this is so bad." Especially because even with Faith, however difficult her circumstances are, and they are very sad, you also witness...I don't know if it's optimism exactly, but this sort of, "I do have power over my life. I can figure out ways of finding joy and happiness, and I'm going to hustle and figure it out." And I think that's just amazing to witness, how much even when life is just happening to Faith, and many other women, they figure it out.