Trent Focus for Research and Development in Primary Health Care

Question Trent Focus for Research and Development in Primary Health Care An Introduction to Qualitative Research BEVERLEY HANCOCK TRENT FOCUS GROUP An Introduction to Qualitative Research AUTHOR: Beverley Hancock Division of General Practice University of Nottingham PRODUCED BY: TRENT FOCUS GROUP 1998 (UPDATED 2002) 1998. Copyright of the Trent Focus Group This resource pack is one of a series produced by the Trent Focus Group. This series has been funded by the Research and Development Group of NHS Executive Trent. This resource pack may be freely photocopied and distributed for the benefit of researchers. However it is the copyright of the Trent Focus Group and the authors and as such no part of the content may be altered without the prior permission in writing of the Copyright owner. Reference as: Hancock Beverley. Trent Focus for Research and Development in Primary Health Care: An Introduction to Qualitative Research. Trent Focus 1998 AN INTRODUCTION TO QUALITATIVE RESEARCH Table of Contents Introduction Section 1: The nature of qualitative research Section 2: Qualitative research designs Section 3: Methods of collecting qualitative data Section 4: Handling qualitative research data Section 5: Analysing qualitative results Section 6: Presenting the results of qualitative research Summary Feedback on exercises Further reading Glossary AN INTRODUCTION TO QUALITATIVE RESEARCH Introduction A starting point in trying to understand the collection of information for research purposes is that there are broadly two approaches: quantitative research and qualitative research. Early forms of research originated in the natural sciences such as biology chemistry physics geology etc. and was concerned with investigating things which we could observe and measure in some way. Such observations and measurements can be made objectively and repeated by other researchers. This process is referred to as “quantitative” research. Much later along came researchers working in the social sciences: psychology sociology anthropology etc. They were interested in studying human behaviour and the social world inhabited by human beings. They found increasing difficulty in trying to explain human behaviour in simply measurable terms. Measurements tell us how often or how many people behave in a certain way but they do not adequately answer the question “why?”. Research which attempts to increase our understanding of why things are the way they are in our social world and why people act the ways they do is “qualitative” research. The purpose of this resource pack is to enable primary health care professionals with little or no previous experience of research to gain a basic understanding of qualitative research and the potential for this type of research in primary health care. The pack begins with a general introduction into the nature of qualitative research. This includes identification of the strengths and weaknesses of qualitative research in a brief comparison with quantitative research. This is followed by short descriptions of the main qualitative approaches and ways of collecting information. Clear and practical guidance is provided on techniques for analysing and presenting information. Theoretical information is reinforced through exercises and examples drawn from primary health care. • • • • LEARNING OBJECTIVES To provide the reader with a basic understanding of qualitative research. To equip the reader with sufficient information to appreciate how qualitative research is undertaken. To enable prospective researchers to consider the appropriateness of a qualitative approach to their chosen field of investigation. To provide practitioners contemplating or undertaking qualitative research for the first time with guidance on the collection and analysis of data. 1 AN INTRODUCTION TO QUALITATIVE RESEARCH Section 1: The nature of qualitative research Qualitative research is concerned with developing explanations of social phenomena. That is to say it aims to help us to understand the world in which we live and why things are the way they are. It is concerned with the social aspects of our world and seeks to answer questions about: • • • • • Why people behave the way they do How opinions and attitudes are formed How people are affected by the events that go on around them How and why cultures have developed in the way they have The differences between social groups Qualitative research is concerned with finding the answers to questions which begin with: why? how? in what way? Quantitative research on the other hand is more concerned with questions about: how much? how many? how often? to what extent? Further features of qualitative research and how it differs from quantitative research are listed below. • Qualitative research is concerned with the opinions experiences and feelings of individuals producing subjective data. • Qualitative research describes social phenomena as they occur naturally. No attempt is made to manipulate the situation under study as is the case with experimental quantitative research. • Understanding of a situation is gained through an holistic perspective. Quantitative research depends on the ability to identify a set of variables. • Data are used to develop concepts and theories that help us to understand the social world. This is an inductive approach to the development of theory. Quantitative research is deductive in that it tests theories which have already been proposed • Qualitative data are collected through direct encounters with individuals through one to one interviews or group interviews or by observation. Data collection is time consuming. • The intensive and time consuming nature of data collection necessitates the use of small samples. • Different sampling techniques are used. In quantitative research sampling seeks to demonstrate representativeness of findings through random selection of subjects. Qualitative sampling techniques are concerned with seeking information from specific groups and subgroups in the population. • Criteria used to assess reliability and validity differ from those used in quantitative research • A review of textbooks reveals a variety of terms used to describe the nature of qualitative and quantitative research. Some of the common terms are listed in Table 1. 2 AN INTRODUCTION TO QUALITATIVE RESEARCH Qualitative Research Quantitative Research Subjective Holistic Phenomenological Anti positivist Descriptive Naturalistic Inductive Objective Reductionist Scientific Positivist Experimental Contrived Deductive Table 1: Comparison of qualitative and quantitative research terms. Each of the various features of qualitative research may be viewed as a strength or as a weakness. This depends on the original purpose of the research. For example one common criticism levied at qualitative research is that the results of a study may not be generalisable to a larger population because the sample group was small and the subjects were not chosen randomly. But the original research question may have sought insight into a specific subgroup of the population not the general population because the subgroup is “special” or different from the general population and that specialness is the focus of the research. The small sample may have been necessary because very few subjects were available such as is the case with some ethnic groups or patient groups suffering from a rare condition. In such studies generalisibility of the findings to a wider more diverse population is not an aim. EXERCISE 1 Look at the research projects listed below. In which projects would you expect to see a qualitative approach used and in which projects would you expect to see a quantitative approach? Why? A) A comparison of the effectiveness of drug A versus drug B in the treatment of migraine. B) An exploration of the role of the Practice Manager in the primary health care team: a study of four practices. C) A descriptive study of school nurses’ experiences of dealing with boys who have eating disorders. D) A national survey of patients’ knowledge of the causes of heart disease. 3 AN INTRODUCTION TO QUALITATIVE RESEARCH Section 2: Qualitative research designs In this section four major types of qualitative research design are outlined. They are: 1) phenomenology 2) ethnography 3) grounded theory 4) case study Another common research design is the survey. Surveys can be either qualitative or quantitative in their approach to data collection. A description of qualitative surveys can be found in another Trent Focus resource pack. Phenomenology The terminology used by different authors can be very confusing and the use of the term phenomenology is one example. In Table 1 in Section 1 of this pack phenomenology was listed as one of the terms used to describe qualitative research generally. However it is also used to describe a particular type of qualitative research. Phenomenology literally means the study of phenomena. It is a way of describing something that exists as part of the world in which we live. Phenomena may be events situations experiences or concepts. We are surrounded by many phenomena which we are aware of but not fully understand. Our lack of understanding of these phenomena may exist because the phenomenon has not been overtly described and explained or our understanding of the impact it makes may be unclear. For example we know that lots of people are carers. But what does “caring” actually mean and what is it like to be a carer? Back pain is another example. Correlation studies may tell us about the types of people who experience back pain and the apparent causes. Randomised controlled trials of drugs compare the effectiveness of one analgesia against another. But what is it actually like to live with back pain? What are the effects on peoples’ lives? What problems does it cause? A phenomenological study might explore for example the effect that back pain has on sufferers’ relationships with other people by describing the strain it can cause in marriages or the effect on children of having a disabled parent. Phenomenological research begins with the acknowledgement that there is a gap in our understanding and that clarification or illumination will be of benefit. Phenomenological research will not necessarily provide definitive explanations but it does raise awareness and increases insight. Ethnography Ethnography has a background in anthropology. The term means “portrait of a people” and it is a methodology for descriptive studies of cultures and peoples. The cultural parameter is that the people 4 AN INTRODUCTION TO QUALITATIVE RESEARCH under investigation have something in common. Examples of parameters include: • • • • geographical – a particular region or country religious tribal shared experience In health care settings researchers may choose an ethnographic approach because the cultural parameter is suspected of affecting the population’s response to care or treatment. For example cultural rules about contact between males and females may contribute to reluctance of women from an Asian subgroup to take up cervical screening. Ethnography helps health care professionals to develop cultural awareness and sensitivity and enhances the provision and quality of care for people from all cultures. Ethnographic studies entail extensive fieldwork by the researcher. Data collection techniques include both formal and informal interviewing often interviewing individuals on several occasions and participant observation. Because of this ethnography is extremely time consuming as it involves the researcher spending long periods of time in the field. Analysis of data adopts an “emic” approach. This means that the researcher attempts to interpret data from the perspective of the population under study. The results are expressed as though they were being expressed by the subjects themselves often using local language and terminology to describe phenomena. For example a researcher may explore behaviour which we traditionally in the westernised medical world would describe as mental illness. However within the population under study the behaviour may not be characterised as illness but as something else – as evidence that the individual is “blessed” or “gifted” in some way. Ethnographic research can be problematic when researchers are not sufficiently familiar with the social mores of the people being studied or with their language. Interpretation from an “etic” perspective – an outsider perspective – may be a misinterpretation causing confusion. For this reason the ethnographic researcher usually returns to the field to check his interpretations with informants thereby validating the data before presenting the findings. Grounded theory This methodology originated with Glaser and Strauss and their work on the interactions between health care professionals and dying patients. The main feature is the development of new theory through the collection and analysis of data about a phenomenon. It goes beyond phenomenology because the explanations that emerge are genuinely new knowledge and are used to develop new theories about a phenomenon. In health care settings the new theories can be applied enabling us to approach existing problems in a new way. For example our approaches to health promotion or the provision of care. One example of grounded theory with which many of us are familiar is theory about the grief process. Researchers observed that people who were bereaved progressed through a series of stages and that each stage was characterised by certain responses: denial anger acceptance and resolution. This is 5 AN INTRODUCTION TO QUALITATIVE RESEARCH not a new phenomenon people have going through these stages for as long as society has existed but the research formally acknowledged and described the experience. Now we use our knowledge of the grief process new knowledge derived from grounded theory to understand the experience of bereavement and to help the bereaved to come to terms with their loss. We recognise when a person is having difficulty coming to terms with loss because we use the knowledge to recognise signs of “abnormal” grief and can offer help. Various data collection techniques are used to develop grounded theory particularly interviews and observation although literature review and relevant documentary analysis make important contributions. A key feature of grounded theory is the simultaneous collection and analysis of data using a process known as constant comparative analysis. In this process data are transcribed and examined for content immediately following data collection. Ideas which emerge from the analysis are included in data collection when the researcher next enters the field. For this reason a researcher collecting data through semi structured interviews may gradually develop an interview schedule in the latter stages of a research project which looks very different to the original schedule used in the first interview. New theory begins its conception as the researcher recognises new ideas and themes emerging from what people have said or from events which have been observed. Memos form in the researcher’s consciousness as raw data is reviewed. Hypotheses about the relationship between various ideas or categories are tested out and constructs formed leading to new concepts or understandings. In this sense the theory is “grounded” in the data. As in phenomenology where there are concepts of which we are aware but do not fully understand there are aspects of health care which might be informed by the development of new theory. One example is spirituality. In any holistic programme of care health care professionals may talk about the need to meet the “spiritual needs” of patients. However we understand very little of what this means. At first sight spiritual needs might be interpreted as referring to religious beliefs but many people would say that spiritual needs are more than this. It may be an individual’s sense of well being happiness or peace of mind. Grounded theory research could provide health care professionals with a better framework for providing truly holistic care. Case study Like surveys case study research is one of those research approaches which can take a qualitative or quantitative stance. In this resource pack the qualitative approach to case study is described wherein the value of case study relates to the in depth analysis of a single or small number of units. Case study research is used to describe an entity that forms a single unit such as a person an organisation or an institution. Some research studies describe a series of cases. Case study research ranges in complexity. The most simple is an illustrative description of a single event or occurrence. More complex is the analysis of a social situation over a period of time. The most complex is the extended case study which traces events involving the same actors over a period of time enabling the analysis to reflect changes and adjustments. As a research design the case study claims to offer a richness and depth of information not usually offered by other methods. By attempting to capture as many variables as possible case studies can 6 AN INTRODUCTION TO QUALITATIVE RESEARCH identify how a complex set of circumstances come together to produce a particular manifestation. It is a highly versatile research method and employs any and all methods of data collection from testing to interviewing. Case study research in health care has a range of uses. For example a case study may be conducted of the development of a new service such as a hospital discharge liaison scheme jointly run by health and social services in one locality. Another example of the case study approach would be to describe and analyse organisational change in the planning purchasing or delivery of health services as in Total Purchasing pilot projects. One of the most common uses of the case study is the evaluation of a particular care approach. For example an outreach teenage health service set up as an alternative to general practice based teenage clinics might be evaluated in terms of input impact on the health of teenagers locally and the development of collaborative links with other groups involved in promoting teenage health. One of the criticisms aimed at case study research is that the case under study is not necessarily representative of similar cases and therefore the results of the research are not generalisable. This is a misunderstanding of the purpose of case study research which is to describe that particular case in detail. It is particularistic and contextual. For example the usefulness of an outreach teenage health service would be determined by a number of local factors and an evaluation of the service would take those factors into account. If the service works well it does not automatically mean that the service would work equally well in another part of the country but the lack of generalisability does not lessen the value of the service in the area where it is based. Generalisability is not normally as issue for the researcher who is involved in studying a specific situation. It is an issue for the readers who want to know whether the findings can be applied elsewhere. It is the readers who must decide whether or not the case being described is sufficiently representative or similar to their own local situation. Summary Four type of qualitative research designs approaches have been outlined. They do not form an exhaustive list and some research methods can be applied with either a qualitative or a quantitative orientation. The language of qualitative research is not easy for the novice researcher to understand as it often refers to abstract ideas. This is not helped by diversity in the use of terms among qualitative writers. The differences between the various qualitative research designs can be difficult to understand at first. The differences are quite subtle and are mainly concerned with the original research question the people or situations being studied and the way the data is analysed interpreted and presented. Readers of this resource pack should not worry if they do not fully understand the difference between phenomenology and grounded theory or between ethnography and case study at this stage in their reading. The main purpose of this section is to familiarise the reader with the notion that there are different qualitative methodologies and what the terms mean. 7 AN INTRODUCTION TO QUALITATIVE RESEARCH EXERCISE 2 Consider the following list of research problems and consider what would be the most appropriate qualitative research method for each one. If you think that more than one method would be appropriate explain why. A) The role of Specialist Nurses in community care B) Developing a primary health care service for the Chinese population in one city C) What is advocacy in primary health care? D) An evaluation of the Polyclinic – a one stop primary health care centre 8 AN INTRODUCTION TO QUALITATIVE RESEARCH Section 3: Methods of collecting qualitative data Qualitative approaches to data collection usually involve direct interaction with individuals on a one to one basis or in a group setting. Data collection methods are time consuming and consequently data is collected from smaller numbers of people than would usually be the case in quantitative approaches such as the questionnaire survey. The benefits of using these approaches include richness of data and deeper insight into the phenomena under study. Unlike quantitative data raw qualitative data cannot be analysed statistically. The data from qualitative studies often derives from face-to-face interviews focus groups or observation and so tends to be time consuming to collect. Samples are usually smaller than with quantitative studies and are often locally based. Data analysis is also time consuming and consequently expensive. The main methods of collecting qualitative data are: • individual interviews • focus groups • observation This section provides an overview of these methods. The interview Interviews can be highly structured semi structured or unstructured. Structured interviews consist of the interviewer asking each respondent the same questions in the same way. A tightly structured schedule of questions is used very much like a questionnaire. The questions may even be phrased in such a way that a limited range of responses can be elicited. For example: “Do you think that health services in this area are excellent good average or poor? Bearing in mind the cost of conducting a series of one to one interviews the researcher planning to use structured interviews should carefully consider the information could be more efficiently collected using questionnaires. Semi structured interviews (sometimes referred to as focused interviews) involve a series of open ended questions based on the topic areas the researcher wants to cover. The open ended nature of the question defines the topic under investigation but provides opportunities for both interviewer and interviewee to discuss some topics in more detail. If the interviewee has difficulty answering a question or provides only a brief response the interviewer can use cues or prompts to encourage the interviewee to consider the question further. In a semi structured interview the interviewer also has the freedom to probe the interviewee to elaborate on the original response or to follow a line of inquiry introduced by the interviewee. An example would be: Interviewer: “I’d like to hear your thoughts on whether changes in government policy have changed the work of the doctor in general practice. Has your work changed at all?” Interviewee: “Absolutely! The workload has increased for a start.” 9 AN INTRODUCTION TO QUALITATIVE RESEARCH Interviewer: “In what way has it increased?” Unstructured interviews (sometimes referred to as “depth” or “in depth” interviews have very little structure at all. The interviewer goes into the interview with the aim of discussing a limited number of topics sometimes as few as one or two and frames the questions on the basis of the interviewee’s previous response. Although only one or two topics are discussed they are covered in great detail. The interview might begin with the interviewer saying: “I’d like to hear your views on the GP role in PCTs”. Subsequent questions would depend on how the interviewee responded. Unstructured interviews are exactly what they sound like – interviews where the interviewer wants to find out about a specific topic but has no structure or preconceived plan or expectation as to how they will deal with the topic. The difference with semi structured interviews…

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