Catherine Pope

Analysing qualitative data

This is the second in a series of three articles Contrary to popular perception, qualitative research can produce vast amounts of data. These may include verbatim notes or transcribed recordings of interviews or focus groups, jotted notes and more detailed “fieldnotes” of observational research, a diary or chronological account, and the researchers reflective notes made during the research. These data are not necessarily small scale: transcribing a typical single interview takes several hours and can generate 20–40 pages of single spaced text. Transcripts and notes are the raw data of the research. They provide a descriptive record of the research, but they cannot provide explanations. The researcher has to make sense of the data by sifting and interpreting them. #### Summary points Qualitative research produces large amounts of textual data in the form of transcripts and observational fieldnotes The systematic and rigorous preparation and analysis of these data is time consuming and labour intensive Data analysis often takes place alongside data collection to allow questions to be refined and new avenues of inquiry to develop Textual data are typically explored inductively using content analysis to generate categories and explanations; software packages can help with analysis but should not be viewed as short cuts to rigorous and systematic analysis High quality analysis of qualitative data depends on the skill, vision, and integrity of the researcher; it should not be left to the novice In much qualitative research the analytical process begins during data collection as the data already gathered are analysed and shape the ongoing data collection. This sequential analysis1 or interim analysis2 has the advantage of allowing the researcher to go back and refine questions, develop hypotheses, and pursue emerging avenues of inquiry in further depth. Crucially, it also enables the researcher to look for deviant or negative cases; that is, …

Qualitative research in health care

This fully revised and updated edition of Qualitative Research in Health Care offers a clear and accessible introduction to conducting and interpreting qualitative research, incorporating new examples, references and chapters relevant for a comprehensive introduction to the subject. New chapters and references include: • Synthesising qualitative research • Secondary analysis of primary data • Ethical issues • Mixed research methods and integrating qualitative with quantitative techniques • Consensus and other methods for eliciting public and professional views and preferences • Conversation analysis

Qualitative research in health care: Assessing quality in qualitative research

This is the first in a series of three articles In the past decade, qualitative methods have become more commonplace in areas such as health services research and health technology assessment, and there has been a corresponding rise in the reporting of qualitative research studies in medical and related journals.1 Interest in these methods and their wider exposure in health research has led to necessary scrutiny of qualitative research. Researchers from other traditions are increasingly concerned to understand qualitative methods and, most importantly, to examine the claims researchers make about the findings obtained from these methods. The status of all forms of research depends on the quality of the methods used. In qualitative research, concern about assessing quality has manifested itself recently in the proliferation of guidelines for doing and judging qualitative work.2–5 Users and funders of research have had an important role in developing these guidelines as they become increasingly familiar with qualitative methods, but require some means of assessing their quality and of distinguishing “good” and “poor” quality research. However, the issue of “quality” in qualitative research is part of a much larger and contested debate about the nature of the knowledge produced by qualitative research, whether its quality can legitimately be judged, and, if so, how. This paper cannot do full justice to this wider epistemological debate. Rather it outlines two views of how qualitative methods might be judged and argues that qualitative research can be assessed according to two broad criteria: validity and relevance. #### Summary points Qualitative methods are now widely used and increasingly accepted in health research, but quality in qualitative research is a mystery to many health services researchers There is considerable debate over the nature of the knowledge produced by such methods and how such research should be judged Antirealists argue …

Rigour and qualitative research.

Various strategies are available within qualitative research to protect against bias and enhance the reliability of findings. This paper gives examples of the principal approaches and summarises them into a methodological checklist to help readers of reports of qualitative projects to assess the quality of the research. In the health field--with its strong tradition of biomedical research using conventional, quantitative, and often experimental methods--qualitative research is often criticised for lacking scientific rigour. To label an approach “unscientific” is peculiarly damning in an era when scientific knowledge is generally regarded as the highest form of knowing. The most commonly heard criticisms are, firstly, that qualitative research is merely an assembly of anecdote and personal impressions, strongly subject to researcher bias; secondly, it is argued that qualiative research lacks reproducibility--the research is so personal to the researcher that there is no guarantee that a different researcher would not come to radically different conclusions; and, finally, qualitative research is criticised for lacking generalisability. It is said that qualitative methods tend to generate large amounts of detailed information about a small number of settings. The pervasive assumption underlying all these criticisms is that quantitative and qualitative approaches are fundamentally different in their ability to ensure the validity and reliability of their findings. This distinction, however, is more one of degree than of type. The problem of the relation of a piece of research to some presumed underlying “truth” applies to the conduct of any form of social research. “One of the greatest methodological fallacies of the last half century in social research is the belief that science is a particular set of techniques; it is, rather, a state of mind, or attitude, and the organisational conditions which allow that attitude to be expressed.”1 In quantitative data analysis it is possible to generate statistical …

Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research.

Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research.

Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field.

Policy-makers and managers have always used a wide range of sources of evidence in making decisions about policy and the organization of services. However, they are under increasing pressure to adopt a more systematic approach to the utilization of the complex evidence base. Decision-makers must address complicated questions about the nature and significance of the problem to be addressed; the nature of proposed interventions; their differential impact; cost-effectiveness; acceptability and so on. This means that Cochrane-style reviews alone are not sufficient. Rather, they require access to syntheses of high-quality evidence that include research and non-research sources, and both qualitative and quantitative research findings. There is no single, agreed framework for synthesizing such diverse forms of evidence and many of the approaches potentially applicable to such an endeavour were devised for either qualitative or quantitative synthesis and/or for analysing primary data. This paper describes the key stages in reviewing and synthesizing qualitative and quantitative evidence for decision-making and looks at various strategies that could offer a way forward. We identify four basic approaches: narrative (including traditional ‘literature reviews’ and more methodologically explicit approaches such as ‘thematic analysis’, ‘narrative synthesis’, ‘realist synthesis’ and ‘meta-narrative mapping’), qualitative (which convert all available evidence into qualitative form using techniques such as ‘meta-ethnography’ and ‘qualitative cross-case analysis’), quantitative (which convert all evidence into quantitative form using techniques such as‘quantitative case survey’ or ‘content analysis’) and Bayesian meta-analysis and decision analysis (which can convert qualitative evidence such as preferences about different outcomes into quantitative form or ‘weights’ to use in quantitative synthesis). The choice of approach will be contingent on the aim of the review and nature of the available evidence, and often more than one approach will be required.

Qualitative methods in research on healthcare quality

There are no easy solutions to the problem of improving the quality of care. Research has shown how difficult it can be, but has failed to provide reliable and effective ways to change services and professional performance for the better. Much depends on the perspectives of users and the attitudes and behaviours of professionals in the context of their organisations and healthcare teams. Qualitative research offers a variety of methods for identifying what really matters to patients and carers, detecting obstacles to changing performance, and explaining why improvement does or does not occur. The use of such methods in future studies could lead to a better understanding of how to improve quality.

Normalisation process theory: a framework for developing, evaluating and implementing complex interventions

BackgroundThe past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).DiscussionIn this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.SummaryThe NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial.

Impact of surgery for stress incontinence on morbidity: cohort study.

Abstract Objectives: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications. Design: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery. Setting: 18 hospitals in the North Thames region. Subjects: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278. Main outcome measures: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures. Results: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously. Conclusions: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised. Key messages Although surgery improves stress incontinence in most women (87%), only 28% are continent one year later The need for preoperative urodynamic testing should be reappraised Urgency and urge incontinence should not be considered contraindications to surgery Women considering surgery should receive more accurate information on the probability of an improvement in symptoms and possible complications There is a need for a rigorous, pragmatic, randomised trial of surgery for stress incontinence

The ethics of intimate examinations—teaching tomorrow's doctors

The teaching of vaginal and rectal examinations poses ethical problems for students and educators, and guidelines exist to protect patients from unethical practice. Yvette Coldicott and colleagues report an exploratory survey, whose findings suggest that best practice is not always followed and that in many cases consent has not been given for procedures