qualitative research and its uses in health care

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• Volume 55, Issue 2
• Understanding qualitative research in health care
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Qualitative studies are often used to research phenomena that are difficult to quantify numerically. 1,2 These may include concepts, feelings, opinions, interpretations and meanings, or why people behave in a certain way. Although qualitative research is often described in opposition to quantitative research, the approaches are complementary, and many researchers use mixed methods in their projects, combining the strengths of both approaches. 2 Many comprehensive texts exist on qualitative research methodology including those with a focus on healthcare related research. 2-4 Here we give a brief introduction to the rationale, methods and quality assessment of qualitative research.

https://doi.org/10.1136/dtb.2017.2.0457

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Key issues in qualitative research

Qualitative research allows deeper understanding of the richness and complexity of social phenomena. Qualitative methods can provide evidence on health and illness and can be used in various ways: 3

To complement quantitative methods, or when quantitative methods are impractical (e.g. when the topic is sensitive, poses measurement problems or is concerned with process and/or interaction; the research population is very small; or for intensive understanding of an innovation before widespread introduction). 3

In the exploratory stages of an applied health research programme, when they may clarify the research question and generate hypotheses. 3 Study design is often described as flexible or ‘emergent’ and researchers may have to adapt a study through a process of ‘progressive focussing’ in response to important but unanticipated findings. 3

To assess a pre-specified hypothesis, as in quantitative research. 3

To study particular experiences in depth rather than population averages or generalisations, and explore experiences from different perspectives. 3 For example, assessment of patient satisfaction is complex and varies between cultures or settings, which can make it difficult to develop quantitative measurement instruments. 5

To involve potential users in development and implementation of interventions. 6

To interpret the findings of quantitative research. 3

For example, in one study, alongside a quantitative review on the efficacy of telephone counselling for informal carers of people with dementia, qualitative methods were used to explore carers' experiences of receiving telephone counselling and counsellors' experiences of conducting telephone counselling. 7 Analysis of quantitative and qualitative results identified areas for improvement.

While the same ethical principles (autonomy, non-maleficence [doing no harm], beneficence and justice) apply equally to both quantitative and qualitative research, the application of these principles should take into account the nature of the research proposed. 3 The risks of serious physical harm arising from qualitative research are rarely as high as in quantitative medical studies. However, such research may cause psychological harm, damage to self-esteem and have an adverse impact on interpersonal relationships. Qualitative researchers should seek to minimise such risks. A ‘good’ interviewer builds rapport, encouraging trust and disclosure. In addition, the interviewer also needs to allow opportunities for the interviewee to withdraw or cease disclosure. 4

People, settings, processes, events or data are sampled in qualitative research in order to understand a particular problem, rather than to statistically represent a wider population. In contrast to quantitative methods, where many participants are sampled by randomisation, the small number of participants in qualitative research are often deliberately chosen for their ability to illuminate the research question (known as purposive sampling). 2 , 3 Such sampling may include the selection of outlier cases, cases with maximum variation or homogeneous cases.

Data collection

Methods of collecting data include observation, interviews and focus groups. 3  It is usual to write field notes, but methods can also include video or audio recordings.

Observation

Observation allows researchers to notice events and relationships in a ‘natural’ setting, which may produce insights about which the participants may not be aware. Observation (with varying levels of participation by the researcher in the events being observed) may require a prolonged time period but allows the observer to check their record against an informant's description and note discrepancies. 3

One-to-one interviews are used when the researcher wants to find out something that cannot be directly observed (e.g. how consumers evaluate health services, what understanding and attitudes underlie particular kinds of health behaviour). 3

Good questions in qualitative interviews should be open-ended, neutral, sensitive and clear to the interviewee. 8 , 9 It is usually best to start with questions that the interviewee can answer easily and then proceed to more difficult or sensitive topics. 8 Open questions allow the respondent to answer in their own words and interviews where there is a good rapport may be more likely to create a context in which respondents are prepared to discuss sensitive topics and penetrate beyond a superficial level. 2 , 3 Researchers should monitor their interviewing technique, critically appraise recordings of their interviews and ask others for their comments, noting in particular whether leading questions are being asked, whether cues are picked up or ignored, and whether interviewees are given enough time to explain what they mean. 8

Interviews can be tightly structured or more flexible: 3

A structured (standardised) interview is one in which the wording and order of all questions are exactly the same for every respondent. This aims to ensure that any differences between respondents are not attributable to differences in the questionnaire or research procedures.

A semi-structured interview covers topics on the researcher's agenda, but the phrasing and ordering of questions are tailored to the vocabulary and understanding of respondents, rather than imposing a uniform set of questions, which may be interpreted differently by respondents.

A ‘depth’ or ‘long’ interview, involves no specific set of questions. The participant's perspective on the phenomenon of interest should unfold as the participant and not the researcher views it. 3 The flexibility of such interviews may uncover new unanticipated areas or ideas.

Focus groups

Focus groups (or group interviews) are informal discussions in which participants focus collectively on a topic or issue, usually presented to them (either verbally or in written form) as a vignette to discuss. 3 , 10 Focus group participants (usually 6-8 people) may be existing clusters of people (e.g. family members, friends or work colleagues) or assembled specifically for the research. 10

The advantage of a focus group is the interaction of group participants with each other, as well as with the researcher/moderator. Such interaction is helpful to:

gain access to participants' own assumptions, meanings, vocabulary and thinking patterns;

identify concepts and practices central to the respondents, and to design subsequent questionnaires using respondents' own words or phrases, enhancing future participants' understanding of research questions;

observe how people interact to construct meanings attributed to health and illness, how opinions are formed, expressed, defended and sometimes modified in discussion and debate with others;

enable participants to have more control over the research agenda, which may generate unexpected insights into areas important to them; and

identify obstacles or objections that prevent or discourage individuals from healthy behaviours, and explore individuals' understanding of, and responses to, health-related media messages. 10

Data analysis

Whereas quantitative analysis seeks to reduce data, generating a series of statistics, qualitative analysis aims to represent data using detailed knowledge of cases. Qualitative research studies typically produce very large amounts of data, which are reduced and summarised into codes, concepts, categories, themes and theory. 3

There are many different approaches to analysis in qualitative research, including thematic analysis, framework analysis, grounded theory, interpretive phenomenological analysis, conversation analysis and discourse analysis. 2 , 3 , 11 , 12

Grounded theory derives theory from data using a constant comparative method. 2 , 3 , 11 , 12 Items in the raw data (e.g. interviews, field notes) are broken down, so that as many ideas and concepts as possible are identified and systematically coded, while at the same time comparing them with previous incidents. 2 , 3 Standardised rules are used for transcribing data to limit the risk of misinterpretation. Codes and categories can be based on the respondent's own words. 3 The data are simultaneously organised and reassembled, so that the researcher can identify relevant elements and relationships by cataloguing the substantive topics and attaching labels to concepts and themes that they see emerging from the material (rather than reflecting prior theoretical assumptions), developing core categories and ultimately explaining phenomena. 2 , 3 The analysis is iterative with the findings of preliminary analyses of data from the first phases of fieldwork informing subsequent work. 3

There should be careful documentation of all analytic decisions that lead to the creation of categories, forming an audit trail that provides evidence to support the integrity of the coding, categorisation and interpretive choices made throughout the qualitative data analysis process. 2

Researchers should also demonstrate continuous reflection on the fit between data and reality, by regarding all theoretical explanations, categories, hypotheses and questions about the data as being provisional until they are compared with the data. 3 They should give clear explanations of methods and demonstrate that they have considered alternative possible explanations for their data. 3

A study may be adapted through a process of iterative ‘progressive focussing’ in response to important unanticipated findings. 3 ‘Data saturation’ is a point at which no new themes or ideas arise from data analysis, and data collection can stop at that point.

Researchers' pre-existing assumptions are often challenged by qualitative research, as ideas are raised by respondents and new concepts and theories can develop that help to explain nuance and complexity. 13 Qualitative studies are not seeking statistical generalisability, but to provide insights with applicability to other settings and situations. It is helpful to have the qualitative researchers' description of what they have done and how it was done, so that readers can judge how transferable the findings are to other contexts. 14

Quality assessment

Qualitative methodologies are derived from many fields of social research with different philosophies and underlying assumptions. 3 There is, therefore, more than one correct way to conduct qualitative research, and there are debates and disagreements about qualitative methodology that can be confusing. 15

Quality assessment of qualitative research studies remains a contested area. 16–18 In addition, as qualitative researchers may have an impact on the data, they must show the efforts they undertook to prevent this from influencing the data. 7

Just as the quality of quantitative studies may be assessed using checklists, many checklists are available to help assess qualitative studies. 16 , 17 For example, the Critical Skills Appraisal Programme (CASP) has produced a checklist to aid evaluation of qualitative research (see Box). 19

CASP checklist 19

Screening questions:

Was there a clear statement of the aims of the research?

Is a qualitative methodology appropriate? Is it worth continuing? (Only continue if both these questions are answered ‘yes’).

Was the research design appropriate to address the aims of the research?

Was the recruitment strategy appropriate to the aims of the research?

Were the data collected in a way that addressed the research issue?

Has the relationship between researcher and participants been adequately considered?

Have ethical issues been taken into consideration?

Was the data analysis sufficiently rigorous?

Is there a clear statement of findings?

How valuable is the research?

A more detailed checklist (the COREQ) consists of 32 items in three domains: 20

The research team and reflexivity (covering items such as the researchers' sex, credentials, occupation, experience or training; the relationship with the participants; researchers' biases and assumptions).

The study design (e.g. the theoretical framework, sampling, how participants were approached, the setting, description of the sample, data collection and the audit trail)

Data analysis and reporting (e.g. the number of data coders and description of coding method, whether participant quotations were presented to illustrate the themes, whether data were consistent, and whether themes were clearly presented in the findings).

Comparison between qualitative and quantitative research

The table below summarises some key differences between qualitative and quantitative research.

• View inline

Comparison of quantitative and qualitative research 3

How can qualitative and quantitative research complement each other?

Qualitative research can complement quantitative approaches. Two examples are given below:

Survey research

Qualitative field work (e.g. using observations, interviews or focus groups) to achieve a better understanding of health problems; generation of questions and response options to capture the reality of participants' experiences; qualitative interviews to seek feedback on the perceived meanings and wording of proposed survey questions; quantitative analysis of survey responses from a large, randomly selected sample.

Intervention development and evaluation

Qualitative fieldwork to illuminate the complexity of a health problem, explore barriers and facilitators for change and explore suitable types and designs of treatment or intervention; qualitative methods to involve users in intervention design to ensure that it meets recipient needs and that it is engaging, feasible and sustainable; randomised controlled trial to assess the effectiveness of an intervention; qualitative study to explore how interventions work (and why they don't work) in the real world.

Qualitative research is a technical discipline that is important in providing valuable descriptions of complex phenomena. Qualitative studies differ from quantitative studies in that they often generate rather than test hypotheses; focus on processes, thoughts, feelings and experiences rather than outcomes; and assess small numbers of participants in depth rather than large sample sizes. Such research is designed to capture concepts that are hard to enumerate with quantitative research methods. Findings from qualitative research can enhance the design of other types of research and the implementation of health interventions. Data are often collected using observation, interviews or focus groups, usually recorded and transcribed, which allow the exploration of topics in the respondents' own words and understanding. Analysis of the information must be systematic and transparent; checklists exist to help assess the quality of qualitative studies. Qualitative methods can complement quantitative methods to add a further dimension to research, although there may be issues around the generalisability of results from one context to another. Evidence from qualitative studies can lead to a richer understanding of the complex reality of people's lives and their experience of illness and medical care.

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Qualitative Research in Health Care

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• Peer review
• Priscilla Alderson

Ed Nicholas Mays, Catherine Pope BMJ Publishing Group, pounds sterling10.95, pp 79 ISBN 0 7279 1013 2

Why does evidence from meticulous trials have so little impact on clinical practice? How do the ways in which clinical teams coordinate their work affect patients' outcomes? Why do many people accept advice on “healthy living” but not put it into practice? These and many similar questions relate to the perplexing gaps between research evidence and its effective use, between health services and outcomes, and between personal knowledge and behaviour. The two methods that dominate medical research—measurement and experiment—offer the best means of evaluating specific interventions, but cannot deal with the above questions.

Current over reliance on measuring leaves large areas of inquiry either poorly researched with inappropriate methods or ignored; it is as restrictive as the use of only two drugs for a range of conditions that require the selective use of a dozen remedies.

Qualitative Research in Health Care, a collection of papers first published in the BMJ, gives a concise introduction to the discriminating use of a wider range of methods. It discusses the main uses, benefits, and pitfalls of social science methods: systematic observation; in depth interviews; focus groups; consensus methods; and case studies which explore, explain, or describe complex examples of actual practice. All these methods can analyse the ambiguous, contradictory responses which inevitably emerge when research moves beyond superficial inquiry. The methods can prepare for later quantitative work, or supplement it, or be used independently.

The editors discuss questions integral to every research method, such as how rigorous and representative the work is, how valid, how reliable, and how impartial. They show that qualitative and quantitative methods broadly overlap and complement one another. The crucial question is not “What is the best research method?” but “What is the best method for answering this question?” For anyone who is unconvinced of the value of “soft” research, the appendix debates the relative merits of qualitative and quantitative work.

Only five methods are covered, and little is said about the importance of theory. However, this reader friendly book contains much information of value to health care practitioners, managers, and researchers, and to anyone who is the subject of research or audit, or who uses (or ignores) research evidence. If members of ethics, funding, and editorial committees, who assess research protocols and reports, noted the book's themes and allowed more resources and journal space for qualitative research, then knowledge about health care could be considerably enriched.—PRISCILLA ALDERSON, senior research officer, Institute of Education, University of London

Research Frameworks: Critical Components for Reporting Qualitative Health Care Research

Affiliation.

• 1 Centre for Health Science Education, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
• PMID: 38596348
• PMCID: PMC11000705
• DOI: 10.17294/2330-0698.2068

Qualitative health care research can provide insights into health care practices that quantitative studies cannot. However, the potential of qualitative research to improve health care is undermined by reporting that does not explain or justify the research questions and design. The vital role of research frameworks for designing and conducting quality research is widely accepted, but despite many articles and books on the topic, confusion persists about what constitutes an adequate underpinning framework, what to call it, and how to use one. This editorial clarifies some of the terminology and reinforces why research frameworks are essential for good-quality reporting of all research, especially qualitative research.

Keywords: conceptual frameworks; health care; qualitative research; research frameworks; theoretical frameworks; theory.

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