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Qualitative research in inflammatory bowel disease: Dispelling the myths of an unknown entity
Digestive and Liver Disease 38 (2006) 60–63
Viewpoint
Qualitative research in inflammatory bowel disease: Dispelling the myths of an unknown entity L.C. Vanderheyden a , M.J. Verhoef a,b,∗ , R.J. Hilsden a,b a
Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, Alta., Canada T2N 4N1 b Department of Medicine, University of Calgary, 3350 Hospital Drive NW, Calgary, Alta., Canada T2N 4N1 Received 1 July 2005; accepted 2 September 2005 Available online 10 October 2005
Abstract The potential for qualitative research in the field of inflammatory bowel disease has been overlooked due to a misunderstanding of the methods and intent of this approach. In this paper, we provide a brief overview of qualitative research and address some of the misconceptions and criticisms that we have come across during our use of qualitative research methods in inflammatory bowel disease research. © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Inflammatory bowel diseases; Qualitative research
The quality of research should be assessed by the fit between the research question and the chosen research design [1–3] and not by where the chosen research design fits within a hierarchy of evidence. For example, the randomized controlled trial (RCT), which is typically at the top of the evidence hierarchy, is a superior design to answer questions related to treatment efficacy but not of a descriptive or exploratory nature [1]. Sackett and Wennberg (1997) argue that all designs are valuable, as each design has unique characteristics that makes it appropriate for certain types of questions but inappropriate for others. Rigid adherence to an evidence hierarchy can lead to the misapplication of ‘high quality’ designs to all research questions and to the automatic denigration of research where ‘low quality’ designs have been appropriately matched to the research question. Qualitative research has particularly suffered from being at the bottom of the evidence hierarchy. The intent of qualitative research is to develop concepts that help to understand psychosocial phenomena, such as behaviours, beliefs and processes, in natural and not experimental settings and in the words of those who experience the phenomena [4]. Often qualitative research produces models or hypotheses that may ∗
Corresponding author. Tel.: +1 403 220 7813; fax: +1 403 270 7307. E-mail address: [email protected] (M.J. Verhoef).
be subsequently tested through quantitative methods. Typically, qualitative research deals with words and not numbers and therefore, requires different analytic techniques; however, this does not mean that qualitative research is devoid of measurement, or that it cannot be used to explain or predict psychosocial phenomena [4]. Medical researchers conducting qualitative research often struggle to find acceptance of their work by mainstream biomedical journals and grant review panels. It does not appear that this low regard is due to less interest or belief in the importance of questions that qualitative research is superior to address, rather it seems to stem from a misunderstanding of the underlying philosophy, the methods and the intent of qualitative research. Admittedly, qualitative researchers have somewhat harmed their cause. The non-intuitive and cryptic terminology of qualitative research can make research results inaccessible to researchers trained in a different research tradition. Further, some qualitative researchers are preoccupied with the philosophical assumptions and ideology of qualitative research traditions, which often lead to the belief that qualitative research has little practical importance. A focus on philosophy and not practicality has even led qualitative research zealots to suggest that qualitative research techniques are the only valid modes of inquiry. Finally and disappointingly,
1590-8658/$30 © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2005.09.002
L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63
some researchers have applied qualitative research methods to research questions for which they are clearly inappropriate. In this paper, we provide a brief overview of qualitative research and address some of the misconceptions and criticisms that we have come across during our use of qualitative research methods in inflammatory bowel disease research. Our goal is to dispel some of the common misconceptions regarding qualitative research and to reveal it as a valid and useful approach that can be used to address relevant and meaningful research questions and advance knowledge in the area of inflammatory bowel disease.
1. Quality of life research is not qualitative research More than once we have heard, ‘I do qualitative research; I always include a quality of life measure in my design’. Including quality of life measures in a clinical trial does not constitute qualitative research. Quality of life is a subjective concept, and qualitative research methods have been used very appropriately to study this concept; but, not all quality of life researches are qualitative research. The determining factor is the research question. If the question is how much has quality of life changed as a result of an intervention, then an appropriate research design will include a quantitative quality of life measure pre- and post-intervention. If the question is what does quality of life mean to a patient, then an appropriate research design will include qualitative methods to explore these questions from the perspective of a patient and in their own words.
2. Descriptive research is not qualitative research Another common misconception is that survey or descriptive research can be equated with qualitative research. Again, the distinction between the two is inherent to the research question. If the question is how many patients do not comply with a prescribed treatment, and how does compliance vary by demographic characteristics, then a quantitative survey is required. If the question is why do patients not comply with a prescribed intervention (and not enough is known to develop a quantitative survey), then qualitative research methods are required to explore the reasons from a patient perspective. A second distinction lies around the type of data that are needed. Survey data are usually numerical and can therefore be used to answer questions of how many. Qualitative data are usually narrative and obtained through indepth interviews and can therefore be used to answer questions of why or how.
3. Small sample sizes are required Qualitative methods are used when the goal is to advance a comprehensive model or hypothesis or to explore a phe-
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nomenon from many varied perspectives. Rich and detailed data regarding the phenomenon of interest are required and are typically obtained through indepth interviews [5]. Qualitative research can generate large amounts of data that require a large amount of time, special skills and special software to analyse. It is neither feasible to include a large number of participants and still obtain the same depth, nor is it required by the research purpose. Sample size in qualitative research is subjective; it is a matter assessing the sample size based on the intended research purpose, not a matter of judging the sample size too large or too small [6]. Sample size is often judged by the concept of ‘saturation’. Saturation essentially means that no new information is being learned from new data that are collected in the specific research context.
4. It is not the intent of qualitative research to generalise to larger populations Participants in qualitative research are handpicked and not randomly chosen. It is therefore a common sentiment that the sampling decisions in qualitative research preclude generalization of results to a larger population. While this sentiment is correct, it is incorrect to assume that generalization is the goal. Qualitative methods may be used to systematically explore concepts about which little is known, from the perspective of those who experience them. The intent is to advance, not to test, theories. It is necessary to work with a small number of participants who are willing to discuss their experiences in detail. Further, it is necessary to handpick (or ‘purposefully select’) participants with a range of characteristics related to the concept of interest. If random sampling was used to select such a small sample, there would be no guarantee that participants would be able to or want to adequately contribute to a developing theory, and the interpretation could neither be comprehensive nor reflective of the range of experiences [7]. We do not intend to say that qualitative research results can never be generalised to any population in any context; in fact, some can be. Qualitative researchers are oblidged to provide descriptions of a concept – and the context in which it was observed – with enough detail so that those reading the results can decide for themselves if the results may be applied within their own particular context [8].
5. Participant quotes are used to add credibility to results Although irrelevant in quantitative research, in qualitative research relevant data from individual participants are presented in the results’ section of a report to give credence to interpretations and to illustrate conceptual leaps [5,9]. Qualitative research involves rigorous analysis of narrative text. No analysis of any text is possible without quoting the
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L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63
important and relevant sections of that text. The inclusion of participant quotes adds credibility through an illustration and justification of the researcher’s interpretation based on the participants’ words. In essence, the representation of participant quotes makes qualitative research results more tangible, gives power to the participants’ voice and adds life to a researcher’s interpretation.
6. Research topics in inflammatory bowel disease for which qualitative research is essential There are many research questions in the field of inflammatory bowel disease that are of importance to both clinicians and patients that require qualitative methods. To ignore these issues altogether is to ignore issues of practical importance. To approach these questions with another method may be methodologically substandard. Qualitative methods are a natural choice to explore factors that determine patient behaviours and decision making, for example why do patients ignore medical advice or not comply with medical treatments? When confronted with different treatment options, for example medical versus surgical, what process do patients use to make a decision? What role would patients like their physicians to play in making difficult treatment decisions? What does it mean to be a teenager with inflammatory bowel disease? Each of these research topics clearly requires talking with patients and thus, qualitative research. An appropriate research method would be conducting individual interviews with 15–20 patients who have experience with the phenomena of interest. The simple goal would be to ask questions, try to make sense of the responses and advance theories or hypotheses. There is also a great potential for nesting a qualitative study within an intervention study to explore [2,10]: the process by and context in which outcomes were achieved; the feasibility of implementing an intervention in a real life context; the meaning of the intervention to a patient; unexpected adverse events; and the range of physical, spiritual and emotional outcomes that may result from an intervention.
7. Conclusion We do not intend to favour qualitative research over quantitative research, but only suggest that qualitative research methods represent a set of rigorous tools that can be authoritatively applied to questions of process and meaning: questions for which quantitative methods are inappropriate. In order to appreciate the intricacy of qualitative research methods, however, a more comprehensive review than the one provided here is clearly required and indeed many have been written [4,5,7–9]. Our review is only meant to introduce the reader to the purpose, general methods and intent
Table 1 Summary of the approaches and techniques used in qualitative research What approach is taken? Naturalistic, in participants’ natural setting Non-experimental What methods are used? Individual interviews (structured, semi-structured, indepth), focus groups Participant observation Document review What constitutes data? Interview transcripts Field notes and memos Documents How is data analysed? Coding/indexing of meaningful segments of text Constant comparison of each code with rest of data to develop concepts and themes Iteratively while data is being collected How is quality assessed? Peer review; debriefing Attention to negative or unusual cases Respondent validation/member checking Providing detailed descriptions of codes, concepts and themes and being clear in methods and approach taken
of qualitative research. A summary of specific approaches and techniques used in qualitative research is provided in Table 1. Researchers and clinicians have the tools to recognize and make sense of patterns, while patients have data. To be able to understand a phenomenon experienced by subjects living in their own social context, we need to engage with both the subjects and the context within which they experience the phenomenon. Observations of subjects are crucial but an observer cannot fully understand what a subject is experiencing, especially without asking them. Conflict of interest statement None declared.
References [1] Glasziou P, Vandenbroucke JP, Chalmers I. Assessing the quality of research. Br Med J 2004;328:39–41. [2] Petticrew M, Roberts H. Evidence, hierarchies and typologies: horses for courses. J Epidemiol Community Health 2003;57:527– 9. [3] Sackett DL, Wennberg JE. Choosing the best research design for each question. Br Med J 1997;315:1636. [4] Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Br Med J 1995;311:42–5. [5] Morse JM, Richards L, editors. Readme first: for a user’s guide to qualitative methods. Thousand Oaks: Sage Publications; 2002.
L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63 [6] Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179–83. [7] Miles MB, Huberman AM, editors. Qualitative data analysis: an expanded sourcebook. Thousand Oaks: Sage Publications; 1994. [8] Lincoln YS, Guba EG, editors. Naturalistic inquiry. Thousand Oaks: Sage Publications; 1985.
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[9] Berg B, editor. Qualitative research methods for the social sciences. Boston: Allyn and Bacon; 1989. [10] Verhoef MJ, Casebeer A, Hilsden RJ. Assessing efficacy of complementary medicine: adding qualitative research methods to the ‘Gold Standard’. J Altern Complement Med 2002;8:275– 81.
Viewpoint
Qualitative research in inflammatory bowel disease: Dispelling the myths of an unknown entity L.C. Vanderheyden a , M.J. Verhoef a,b,∗ , R.J. Hilsden a,b a
Department of Community Health Sciences, University of Calgary, 3330 Hospital Drive NW, Calgary, Alta., Canada T2N 4N1 b Department of Medicine, University of Calgary, 3350 Hospital Drive NW, Calgary, Alta., Canada T2N 4N1 Received 1 July 2005; accepted 2 September 2005 Available online 10 October 2005
Abstract The potential for qualitative research in the field of inflammatory bowel disease has been overlooked due to a misunderstanding of the methods and intent of this approach. In this paper, we provide a brief overview of qualitative research and address some of the misconceptions and criticisms that we have come across during our use of qualitative research methods in inflammatory bowel disease research. © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Inflammatory bowel diseases; Qualitative research
The quality of research should be assessed by the fit between the research question and the chosen research design [1–3] and not by where the chosen research design fits within a hierarchy of evidence. For example, the randomized controlled trial (RCT), which is typically at the top of the evidence hierarchy, is a superior design to answer questions related to treatment efficacy but not of a descriptive or exploratory nature [1]. Sackett and Wennberg (1997) argue that all designs are valuable, as each design has unique characteristics that makes it appropriate for certain types of questions but inappropriate for others. Rigid adherence to an evidence hierarchy can lead to the misapplication of ‘high quality’ designs to all research questions and to the automatic denigration of research where ‘low quality’ designs have been appropriately matched to the research question. Qualitative research has particularly suffered from being at the bottom of the evidence hierarchy. The intent of qualitative research is to develop concepts that help to understand psychosocial phenomena, such as behaviours, beliefs and processes, in natural and not experimental settings and in the words of those who experience the phenomena [4]. Often qualitative research produces models or hypotheses that may ∗
Corresponding author. Tel.: +1 403 220 7813; fax: +1 403 270 7307. E-mail address: [email protected] (M.J. Verhoef).
be subsequently tested through quantitative methods. Typically, qualitative research deals with words and not numbers and therefore, requires different analytic techniques; however, this does not mean that qualitative research is devoid of measurement, or that it cannot be used to explain or predict psychosocial phenomena [4]. Medical researchers conducting qualitative research often struggle to find acceptance of their work by mainstream biomedical journals and grant review panels. It does not appear that this low regard is due to less interest or belief in the importance of questions that qualitative research is superior to address, rather it seems to stem from a misunderstanding of the underlying philosophy, the methods and the intent of qualitative research. Admittedly, qualitative researchers have somewhat harmed their cause. The non-intuitive and cryptic terminology of qualitative research can make research results inaccessible to researchers trained in a different research tradition. Further, some qualitative researchers are preoccupied with the philosophical assumptions and ideology of qualitative research traditions, which often lead to the belief that qualitative research has little practical importance. A focus on philosophy and not practicality has even led qualitative research zealots to suggest that qualitative research techniques are the only valid modes of inquiry. Finally and disappointingly,
1590-8658/$30 © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2005.09.002
L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63
some researchers have applied qualitative research methods to research questions for which they are clearly inappropriate. In this paper, we provide a brief overview of qualitative research and address some of the misconceptions and criticisms that we have come across during our use of qualitative research methods in inflammatory bowel disease research. Our goal is to dispel some of the common misconceptions regarding qualitative research and to reveal it as a valid and useful approach that can be used to address relevant and meaningful research questions and advance knowledge in the area of inflammatory bowel disease.
1. Quality of life research is not qualitative research More than once we have heard, ‘I do qualitative research; I always include a quality of life measure in my design’. Including quality of life measures in a clinical trial does not constitute qualitative research. Quality of life is a subjective concept, and qualitative research methods have been used very appropriately to study this concept; but, not all quality of life researches are qualitative research. The determining factor is the research question. If the question is how much has quality of life changed as a result of an intervention, then an appropriate research design will include a quantitative quality of life measure pre- and post-intervention. If the question is what does quality of life mean to a patient, then an appropriate research design will include qualitative methods to explore these questions from the perspective of a patient and in their own words.
2. Descriptive research is not qualitative research Another common misconception is that survey or descriptive research can be equated with qualitative research. Again, the distinction between the two is inherent to the research question. If the question is how many patients do not comply with a prescribed treatment, and how does compliance vary by demographic characteristics, then a quantitative survey is required. If the question is why do patients not comply with a prescribed intervention (and not enough is known to develop a quantitative survey), then qualitative research methods are required to explore the reasons from a patient perspective. A second distinction lies around the type of data that are needed. Survey data are usually numerical and can therefore be used to answer questions of how many. Qualitative data are usually narrative and obtained through indepth interviews and can therefore be used to answer questions of why or how.
3. Small sample sizes are required Qualitative methods are used when the goal is to advance a comprehensive model or hypothesis or to explore a phe-
61
nomenon from many varied perspectives. Rich and detailed data regarding the phenomenon of interest are required and are typically obtained through indepth interviews [5]. Qualitative research can generate large amounts of data that require a large amount of time, special skills and special software to analyse. It is neither feasible to include a large number of participants and still obtain the same depth, nor is it required by the research purpose. Sample size in qualitative research is subjective; it is a matter assessing the sample size based on the intended research purpose, not a matter of judging the sample size too large or too small [6]. Sample size is often judged by the concept of ‘saturation’. Saturation essentially means that no new information is being learned from new data that are collected in the specific research context.
4. It is not the intent of qualitative research to generalise to larger populations Participants in qualitative research are handpicked and not randomly chosen. It is therefore a common sentiment that the sampling decisions in qualitative research preclude generalization of results to a larger population. While this sentiment is correct, it is incorrect to assume that generalization is the goal. Qualitative methods may be used to systematically explore concepts about which little is known, from the perspective of those who experience them. The intent is to advance, not to test, theories. It is necessary to work with a small number of participants who are willing to discuss their experiences in detail. Further, it is necessary to handpick (or ‘purposefully select’) participants with a range of characteristics related to the concept of interest. If random sampling was used to select such a small sample, there would be no guarantee that participants would be able to or want to adequately contribute to a developing theory, and the interpretation could neither be comprehensive nor reflective of the range of experiences [7]. We do not intend to say that qualitative research results can never be generalised to any population in any context; in fact, some can be. Qualitative researchers are oblidged to provide descriptions of a concept – and the context in which it was observed – with enough detail so that those reading the results can decide for themselves if the results may be applied within their own particular context [8].
5. Participant quotes are used to add credibility to results Although irrelevant in quantitative research, in qualitative research relevant data from individual participants are presented in the results’ section of a report to give credence to interpretations and to illustrate conceptual leaps [5,9]. Qualitative research involves rigorous analysis of narrative text. No analysis of any text is possible without quoting the
62
L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63
important and relevant sections of that text. The inclusion of participant quotes adds credibility through an illustration and justification of the researcher’s interpretation based on the participants’ words. In essence, the representation of participant quotes makes qualitative research results more tangible, gives power to the participants’ voice and adds life to a researcher’s interpretation.
6. Research topics in inflammatory bowel disease for which qualitative research is essential There are many research questions in the field of inflammatory bowel disease that are of importance to both clinicians and patients that require qualitative methods. To ignore these issues altogether is to ignore issues of practical importance. To approach these questions with another method may be methodologically substandard. Qualitative methods are a natural choice to explore factors that determine patient behaviours and decision making, for example why do patients ignore medical advice or not comply with medical treatments? When confronted with different treatment options, for example medical versus surgical, what process do patients use to make a decision? What role would patients like their physicians to play in making difficult treatment decisions? What does it mean to be a teenager with inflammatory bowel disease? Each of these research topics clearly requires talking with patients and thus, qualitative research. An appropriate research method would be conducting individual interviews with 15–20 patients who have experience with the phenomena of interest. The simple goal would be to ask questions, try to make sense of the responses and advance theories or hypotheses. There is also a great potential for nesting a qualitative study within an intervention study to explore [2,10]: the process by and context in which outcomes were achieved; the feasibility of implementing an intervention in a real life context; the meaning of the intervention to a patient; unexpected adverse events; and the range of physical, spiritual and emotional outcomes that may result from an intervention.
7. Conclusion We do not intend to favour qualitative research over quantitative research, but only suggest that qualitative research methods represent a set of rigorous tools that can be authoritatively applied to questions of process and meaning: questions for which quantitative methods are inappropriate. In order to appreciate the intricacy of qualitative research methods, however, a more comprehensive review than the one provided here is clearly required and indeed many have been written [4,5,7–9]. Our review is only meant to introduce the reader to the purpose, general methods and intent
Table 1 Summary of the approaches and techniques used in qualitative research What approach is taken? Naturalistic, in participants’ natural setting Non-experimental What methods are used? Individual interviews (structured, semi-structured, indepth), focus groups Participant observation Document review What constitutes data? Interview transcripts Field notes and memos Documents How is data analysed? Coding/indexing of meaningful segments of text Constant comparison of each code with rest of data to develop concepts and themes Iteratively while data is being collected How is quality assessed? Peer review; debriefing Attention to negative or unusual cases Respondent validation/member checking Providing detailed descriptions of codes, concepts and themes and being clear in methods and approach taken
of qualitative research. A summary of specific approaches and techniques used in qualitative research is provided in Table 1. Researchers and clinicians have the tools to recognize and make sense of patterns, while patients have data. To be able to understand a phenomenon experienced by subjects living in their own social context, we need to engage with both the subjects and the context within which they experience the phenomenon. Observations of subjects are crucial but an observer cannot fully understand what a subject is experiencing, especially without asking them. Conflict of interest statement None declared.
References [1] Glasziou P, Vandenbroucke JP, Chalmers I. Assessing the quality of research. Br Med J 2004;328:39–41. [2] Petticrew M, Roberts H. Evidence, hierarchies and typologies: horses for courses. J Epidemiol Community Health 2003;57:527– 9. [3] Sackett DL, Wennberg JE. Choosing the best research design for each question. Br Med J 1997;315:1636. [4] Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. Br Med J 1995;311:42–5. [5] Morse JM, Richards L, editors. Readme first: for a user’s guide to qualitative methods. Thousand Oaks: Sage Publications; 2002.
L.C. Vanderheyden et al. / Digestive and Liver Disease 38 (2006) 60–63 [6] Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995;18:179–83. [7] Miles MB, Huberman AM, editors. Qualitative data analysis: an expanded sourcebook. Thousand Oaks: Sage Publications; 1994. [8] Lincoln YS, Guba EG, editors. Naturalistic inquiry. Thousand Oaks: Sage Publications; 1985.
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[9] Berg B, editor. Qualitative research methods for the social sciences. Boston: Allyn and Bacon; 1989. [10] Verhoef MJ, Casebeer A, Hilsden RJ. Assessing efficacy of complementary medicine: adding qualitative research methods to the ‘Gold Standard’. J Altern Complement Med 2002;8:275– 81.