Qualitative Research What, why and how (...and should I even go there?) Alexander M Clark, PhD BA(Hons) RN Associate Professor, University of Alberta AHFMR Population Health Investigator CIHR New Investigator Alex.Clark@ualberta.ca What is qualitative research? • Research based on non-numerical data • Variety of different: – Philosophical bases – Methods – Data collection techniques • So be wary of oversimplifying diversity… What qualitative research is not… • Not: – ‘Quality of life’ research – Research into quality – Survey with open ended questions – Count the number of particular words Characteristics of qualitative research • Insider’s perspective – Personal involvement – Openness to ‘the other’ • Holistic – Context – Complexity – Depth • Inductive – Responsiveness – Moving beyond the specific • (Morse 1992; Powers and Knapp 1995) Data generation techniques • Research using non-numerical data – Transcribed speech • Focus groups • Interviews – Observational notes • Field observers – Historical documents • • • • Official records Letters Emails! Web pages Qualitative Research: An evolution • 1980s – Low awareness – Difficult to attain funding – Absent from government policy – Marginal presence in medicine journals – Greater presence in social science and nursing journals • 2000s – Moderate awareness – Attractive to funding bodies – Informs government policy – Permeation into most (though not all) mainstream health / medical journals The origin of qualitative research • Understanding the ‘other’ – Imperialist Ethnography – ‘Objective, colonizing accounts of field experiences…(of that which was) alien, foreign and strange’ – Prominent ethnographies: • Native Americans • African tribes Mary Kingsley (1862-1930) ‘Travels in West Africa’ (1897) ‘West African Studies’ (1899) • ‘…a new reason for polygamy…it enabled a man to get enough to eat. This sounds sinister from a notoriously cannibal tribe; but the explanation is that the Fans are an exceedingly hungry tribe, and require a great deal of providing for. It is their custom to eat about ten times a day when in village, and the men spend most of their time in the palaver- houses at each end of the street, the women bringing them bowls of food of one kind or another all day long. When the men are away in the forest rubber or elephanthunting, and have to cook their own food, they cannot get quite so much; but when I have come across them on these expeditions, they halted pretty regularly every two hours and had a substantial snack, and the gorge they all go in for after a successful elephant hunt is a thing to see--once.’ • Gradual movement to less imperialist, more culturally and socially sensitive approaches Summary point 1: What • Qualitative Research now established set of techniques • Uses a variety of techniques to collect non- numerical data • Moved from outsiders’ to insiders’ perspective • Seeks to provide a holistic account based on inductive reasoning Why?: Types of questions • What is the society like? – Social norms – Cultural practices • Why do certain behaviours occur? – Processes – Patterns – Paradoxical – Surprising • What is this experience like? – Nuances – Depth Explaining patterns in data • Increasingly large volume and sophistication in quantitative data collection – Large cohorts – Numerous fields – Automated data linkage and storage • Patterns are increasingly described…but not explained Examples… • Delay in seeking help during heart attack – 90 minute window for clot busting therapy – Average 4 hour delay time to help seeking • Availability of services to reduce risk after heart attack – Evidence of mortality benefit – 30% participation rate – Rates lowest in those in most need What is missing? • All that is useful cannot be quantified – Complexity – Unknown factors – Process – Defies quantification • Values • Aspirations • Human decision-making Example 2: Knowledge utilization • Evidence-based practices rates around 30% • Poor insights into:… – Why guidelines are poorly utilized? – What factors influence implementation of evidence? – What can be done to improve rates… Low compliance • Greater impact on health if existing therapies are used than from new therapies (WHO 2004) • Around 50% ‘compliance’ rates in those with chronic disease • Increasingly strained health care infrastructure to provide professional support Systematic review of qualitative research • Synthesizing findings from a number of studies in a common topic – – – – Meta-synthesis / Meta-ethnography Search strategy Selection criteria Synthesis of bodies of studies Why? Summary Point 2 • Qualitative research can address questions – What is the society like? – Why do certain behaviours occur? – What is this experience like? – Individual studies or reviews How?: Philosophical bases • Constructivism – Relativism • Realism – Critical realism – Postpositivism • Positivism – Objectivism Methods • Grounded theory – Theory around social processes • Phenomenology / Hermeneutics – Experience and meaning • Ethnography – Culture • Document / Historical • Generic A brief overview • Phenomenology Complex lived experience • Grounded theory Theories of the social • Ethnography Culture • Case Study Deep understanding of cases • Generic / Interpretive Descriptive Experiences or perspectives Phenomenology • Focus: • Domain: • Background: The study of phenomena Being, lived experiences, essences Philosophy • Names: Husserl, Heidegger, Gadamer • Data collection: One to one interviews Use of phenomenology in health research • Meaning – Experiences • Living – Illnesses / Health • Perspectives – Beliefs, decision-making, judgments… • Understanding • Beck (1992) PPD – DSMIV – Personal experience • Bowman (1991) Chronic back pain – Pain scores – Effect on independence, living and health Where is meaning in a text? • Writer – What is intended? • Text – What is inherent? • Reader – What I interpret? What will a phenomenological study look like? • Justification for examining the human experience • Sample size usually 5-30 people • Insiders’ account • Deep analysis of dimensions of phenomena under study Interpretive descriptive / G eneric • Focus: Descriptive study of themes • Domain: Subjective experience, perspectives, beliefs, knowledge…. • Background: Applied sciences • Names: Many… • Data collection: Semi-structured interviews What will an interpretive descriptive study look like? • Has no specific methodological label – ‘Thematic analysis’ ‘Interpretive analysis’ – ‘Qualitative research’ • Sample size usually 5-30 people • Insiders’ account Use of ID in health research • Health and Illness experience – – – – Myocardial infarction Breat cancer survivor Perspectives Beliefs, knowledge decision-making, judgments… • Goal: Understanding • Accessing support services – Tod et al (2002) • Learning needs of patients – Wehby and Brenner (1992) • Explanatory models for symptoms – Russell et al (1998) Ethnography • Focus: The study of cultures • Domain: Macro and micro cultures • Background: Cultural anthropology • Names: Mead, Atkinson, Hammersley • Data collection: Observation, group-work, interviews ‘Ethnography is appropriate if the needs are to describe how a cultural group works and to explore beliefs, language, behaviours and issues such as power, resistance and dominance.’ – Creswell (2007, page 70) Use of ethnography in health research Culture Places Settings Populations Macro Town Vulnerable population Micro Families Student group on a course • Porter and Ryan (1996) – Racist behaviour in clinical settings • Preston (1997) – Families of people with CHD What will an ethnographic study look like? • Clear specification of a group under study and justification for this • Perhaps some mention of a key informant • Would engage in field work – Observational data collection – Oral data collection – Cultural artifacts • Build up a research cultural portrait / account Grounded Theory • ‘…to move beyond description…to generate or discover a theory, an abstract analytical schema of a process (or action or interaction).’ Cresswell (2007, pg 63) • Theory is grounded in the data Grounded theory • Focus: • Domain: • Background: Developing theory grounded in data Social processes and interactions Applied • Names: Glaser, Strauss • Data collection: One to one interviews Use of grounded theory in health research Social Processes Interactions Actions Paterson (2001) Empowerment in chronic illness Jillings (2007) Self care processes during heart failure Johnson (1990) Adjustment after myocardial infarction Case study • ‘…study of an issue explored through one of more cases in a bounded system – Cresswell (2007, pg 73) Case study • Focus: • Domain: • Background: A case related to an issue Many…as long as it helps illustration Social science, health, psychology • Names: Stake • Data collection: Multiple (paper, verbal, visual) Use of case study in health research Cases that are particularly Typical Atypical Noteworthy Interesting Illustrative • Power and powerlessness in homecare – Efraimsson et al • Program for prevention of heart disease Bradley et al (1999) Could be: Individual(s), groups, programs, activities…. How? Data collection techniques • Interview – Unstructured – Semi-structured – Structured • • • • • Focus group Observational Video Internet Document extraction Judging quality in qualitative research • Trustworthiness – Do we understand? – Do we agree? • Credibility – Can we follow? • Typicality – Site – Sample Quality Screening • Contentious issues – For what purpose? • Inclusion / Exclusion • Commentary – How expressed? • Measured? • Narrative Is a qualitative methodology appropriate? • How well justified? – Nature of the research question – Existing knowledge of topic area • Does it seem logical / sensible? • Any evidence of alternatives being considered or appropriate? – Survey What design appropriate to question ? • Decision-making clear and appropriate? – Convincing • What is the design called? – What is the design irrespective of what it is called? Was the recruitment strategy appropriate? • Participants • • • • How selected? Most appropriate Typicality Size of sample Addressing the research issue • Setting – Justified – Typical v Atypical • Data collection – Method clear – Justification appropriate • Size – Sample size – Depth of analysis Ethics • Issues of: – Confidentiality – Consent / Process nature of consent – Approval from ethics commitee Rigor of analysis • Is analysis process described? • Is it clear how themes emerged from the data? • Are the findings supported by the data? • Was ‘contradictory’ data examined? Clear statement of findings? • Are findings clear / explicit? • Are issues of credibility addressed? • Does the study refer back to the research questions? Value of the research • What contribution to knowledge does the study make? – How far can they transfer findings to different populations / settings /countries? • What is the significance of this? – Insight – New knowledge How?: Summary Point 3 • Qualitative research is very diverse – Various methods • But there can be underlying / transcending principles of methodological quality • We can draw on these to appraise qualitative studies Useful references • Murphy E, Dingwall R, Greatbatch D, Parker S, Watson P. Qualitative research methods in health technology assessment: a review of the literature. Health Technol Assess 1998; 2(16). • http://www.refer.nhs.uk/ViewRecord.asp?id= 87 • Alex.Clark@ualberta.ca