This article introduces medical researchers to different qualitative methodologies and approaches. To demonstrate the potential for these methods which are typical of the social sciences and humanities, we will undertake a closer examination of six distinct qualitative methods: surveys and interviews, participant observation and focus groups, and document and archival research. Our article will highlight how these tools allow researchers to generate empirically grounded knowledge, while specifying the strengths and weaknesses of each, and the contexts in which they are best used.
A unifying feature of all is their relationship to notions of validity and significance. In quantitative studies, validity is gained by ensuring a large enough sample size such that statistical tests may be performed to demonstrate, among other things, “significance” (defined according to the likelihood of a predetermined outcome occurring by chance). However, in qualitative work, validity does not depend on the numerical quantity of participants. More important is the depth of researchers’ methodological engagement.
Taking the question of treatment refusal, for example, the qualitative researcher would not assume the importance of one factor in the phenomenon under study, say financial cost, but would try to obtain a lower number of highly detailed interviews. These long conversations would allow each participant to fully explore their subjective social, political, emotional, and financial experience, such that the likely complex and interwoven reasons for refusal may come to light. Whereas a quantitative method would demand the comparison of discrete variables from a high number of participants to make statistically valid statements, a qualitative approach leaves open the opportunity for differing responses, the work gaining validity instead from the quality and richness of the information so generated.
SURVEYS AND INTERVIEWS
The first two methods, surveys and interviews, focus on individual participants within a wider group [Figure 1]. Surveys involve the formulation of a highly structured set of questions which are then distributed to participants, who respond without additional input from the researcher. Surveys may be self-administered, completed either in person or online. They include targeted, specific questions and seek focused responses of participants. In certain instances, surveys may give respondents more space to use their own language and ideas to express their answers, so generating detailed written evidence in response to research questions. As structured research tools, surveys ensure that all participants are asked the same set of questions, which is useful when generating responses with the aim of making direct comparisons. However, the structured nature can also be a limitation, as it requires the researcher to make decisions about the themes to be explored and questions to be asked before contact with participants.
Interviews, in contrast, allow a more flexible approach to be taken, and while they can also be highly structured (the researcher sticking to a tightly defined set of questions), they are often “semi-structured.” This means that the researcher will approach each interview with a set of broad themes to explore but will allow a participant’s responses to direct further questions and elaborations. This method is therefore more flexible; it is shaped as much by the participants and their ideas as by the researcher.
To illustrate how rich and detailed the materials produced by semi-structured interviews can be, one can think of the question of personal relationship among cancer patients. Cancer and cancer treatment often have an important impact on a patient’s relationships such as their marriage, sexuality, gender, or relationship with their siblings. This reality, because it is profoundly personal and intimate, is generally difficult to capture through surveys. By contrast, detailed interviews conducted by researchers with cancer patients offer unique opportunities to build trust with participants, to reassure them about their anonymity within the study, and hence to collect precious data on these difficult subjects.
While surveys generate a ready-to-use written document, interviews are commonly audio recorded and then fully transcribed. As in-depth interviews require greater time, a smaller number of respondents are included in this research, and they are chosen with great care. However, qualitative researchers should not assume participants’ capacity to speak on behalf of a wider social or professional group.
Given these relative strengths and weaknesses, surveys and interviews are sometimes used in combination. Frequently, this takes the following form: a researcher might use surveys to get a broad sense of the themes that are important to the research, before conducting a smaller set of more detailed interviews, to fully elucidate the complex interrelations of economics, culture, politics, familial relationships, and so forth that are at play in the decisions made by both patients and medical professionals when it comes to health and healing.
PARTICIPANT OBSERVATION AND FOCUS GROUPS
The second group of methods involves more than one participant at a time: participant observation and focus groups.
Qualitative research in health and medicine emphasizes the importance of the situated and the empirical, and in this regard, participant observation can be highly useful as a research tool. Simply put, this method requires the extended involvement of researchers in the context that they are exploring. Their exact function when they conduct their work is variable; in some instances, they might participate fully in the activity under research – this might be appropriate, for example, if the researcher is a medical doctor working within a hospital. More often in the medical sphere, participation is limited, and the role of the researcher is primarily that of an observer.
The site of such research is often termed the “field” and, like its duration and focus, will depend on the questions asked by the research. If, for example, studying the functioning of different disciplines within an institution, the bounded field site could be that particular institution. If, however, the question of interest extends across time and space, for example, the movement and the use of a particular piece of equipment or a therapeutic, the “field” might include several spaces through which that object moves. In either case, however, multiple different contexts exist in even a single institution, and the same object (be it a piece of diagnostic equipment, a concept such as a diagnosis, or a therapeutic agent such as a tablet) should not be assumed to be consistent in each. The value of extended participant observation lies in the time and space it gives for the researcher to move between these different spaces, documenting the often varied ways in which practices are carried out, discourses are employed, roles are allocated, status is assumed, time and space is managed, objects are used, routines are established or dismantled, relationships are enacted, and so forth.
In empirical research conducted within clinical settings, answers sometimes tend to be stereotyped. For instance, when medical or paramedical staff members are asked to describe their responsibilities, they may respond by stressing the official functions attributed to their professional body. However, financial difficulties, social hierarchies, personal convictions, or varying management styles often lead professional practice to differ from the way tasks are supposed to be distributed. The difference between theory and practice can even be a difficult subject to tackle with a respondent that the researcher meets for the first time, because it involves legal, financial, and ethical issues. In this context, participant observation enables the researcher to understand the various ways in which clinical practice differs from official standards and protocols. By allowing qualitative researchers to understand what people do and why, observation helps refine the research questions and invites the investigator to conduct further interviews about social actors’ motivations.
Although participant observation allows the collection of a broader quantity of data than interviews and can lead to unexpected findings, it is also the case that a researcher’s presence can be experienced as intrusive by participants and care needs to be taken such that it is done in an ethical manner. Where a more controlled environment is required, collective research through focus groups may be more appropriate. Focus groups are in effect a researcher-led conversation among a small group, again selected according to the objectives of the research. The themes covered by the conversation are directed by the researcher, and data are collected through both individual and group responses. Importantly, however, even the most carefully selected group may not produce representative evidence. Communal dynamics can result in the relative suppression of minority points of view or hesitancy in discussing particular themes (the financial or familial strain of treatment, for example). These limitations must therefore be carefully considered.
DOCUMENT AND ARCHIVAL RESEARCH
’The final qualitative research methods to be closely examined are those that do not directly involve human participants at all: document and archival research [Figure 2]. While the former tends to refer to the analysis of contemporary documents and the latter to those from the past, they are similar methods. Document research and archival research both involve the collection of already produced materials pertaining to a research question, and their examination and interpretation considering that question. Many different types of materials can be drawn upon to generate empirical evidence, broaden understanding, or define meaning in this manner. This includes public documents such as newspaper reports, medical journal articles, court proceedings, advertisements, websites, and so forth, as well as private documents from both institutions (hospitals and regulatory authorities etcetera) and individuals such as letters, e-mails, or logbook or diary entries.
The kind of materials chosen for analysis will depend on the questions being posed by the research. Document analysis could help understand a patient’s medical history and journeys, for example. It can deepen understandings gained through interviews, observations, or surveys. Documentary analysis can also be employed to generate evidence of a contemporary or historic public discussion around a relevant treatment or disease. Archival research using a database of newspaper articles, for example, could be used to understand the ways in which way a particular condition or medical institution (if well known) has been portrayed to certain members of the public. Qualitative researchers thus approach medical and nonmedical documents as equally valid forms of knowledge, each of which have plenty to offer when seen as situated discourses through which ideas around health and medicine are collected and available in the form of narratives.
In this kind of research, however, it is often not simply the documents alone that are of interest. The first article in this series on qualitative research noted the centrality of social theory (particularly the study of relations) to this kind of work. In this instance too then, it is often not enough for the qualitative researcher to simply examine the contents of documents for what claims they make or what claims are made on their behalf. In addition, it is also important to explore the ways in which documents relate to the people, practices, places, and other objects around them, each of which may be informed by (or inform) one another.
This kind of research can be convenient as it is a relatively unobtrusive form of data collection, particularly when using online sources such as digitized journal archives or medical forums. However, it is also important to note the limitations of this kind of work. Written materials may be incomplete or inaccurate, and, depending on the language in which they have been recorded, primarily represent the views and experiences of only a certain section of people - those who are literate, and often members of particular professions (journalists, medical staff, or academic researchers, for example). Further, debate exists on the respective validity of written versus oral evidence. While the written word typically commands higher reverence in terms of reliability (few historians would make claims without the backing of written historical sources for example), oral testimony allows the asking of questions and the clarification of ideas. It is thus not always straightforward to assume the primacy of written over oral traditions.
CHOOSING A METHODOLOGY
As has been reiterated throughout this article, the choice of methods in qualitative research depends on the questions that the investigators want to explore[Table 1] (Table 1 summarises their advantages and limitations). For example, while focus groups can be useful for talking about patients’ experiences of care services, this method may not be ideal to understand phenomena directly related to people’s personal lives. Issues such as compliance or refusal of certain treatments because they are linked to potentially sensitive matters (financial problems, tensions within the family, and psychological distress) are better addressed through observation and interviews.
Methods can be fruitfully combined to produce more detailed accounts of social reality. In interviews conducted with medical and paramedical staff members of a hospital, for example, participants are likely to describe harmonious relationships among the various professions and medical specialties. Observation may nonetheless reveal that daily activities are characterized by professional tensions and rivalries. After noticing this discrepancy, investigators can try to alter the way they frame questions during interviews to invite their interlocutors to express their views on these tensions.
Another example would be patients’ use of alternative medicines: in the presence of a biomedical practitioner, many refuse to acknowledge that they have undergone homeopathic or ayurvedic treatment. However, by recording their life stories through in-depth interviewing, carefully tracing their therapeutic journeys in a context of confidentiality and trust, investigators can understand the exact role of alternative therapies in patients’ trajectories. As a consequence, the combination of observation and life stories leads investigators to understand the many attempts of patients to access different kinds of health care and their fears, hopes, and efforts to get well.
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