6. Qualitative Research

Qualitative research does not require numbers. Basically, it asks why we make the decisions we do.
This chapter contains the following sections:

Qualitative research does not require statistics as it is not based on numbers, and many would-be researchers are attracted to this. It can help us to understand problems such as why people behave in such a way.

Why do young people still start to smoke despite knowing the risks? Did drug addicts really believe that they alone would be able to stop heroin whenever they wanted? Why do girls fail to use contraception and then wonder why they got pregnant?

This is not a soft option for research. It is easy to do it badly but doing it well is very demanding.

Quantitative or Qualitative Research?

Numbers tell a story

William Thomson (1827-1907), later to become Lord Kelvin wrote, “I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be.”

It is possible to put numerical values on many things that may seem “touchy feely” such as degree of satisfaction or feeling of wellbeing. However, some knowledge does not lend itself to this type of interpretation. This is qualitative as opposed to quantitative research.

Qualitative research is easy to portray it as the poor relation but it really is quite demanding in terms of methodology and nothing like as simple as some would think; at least not if it is done well.

Numbers help understanding

Qualitative research is often conducted in the field of sociology or behavioural science. It enables issues to be explored. It is often used in marketing and also in politics with focus groups. They latter is really marketing. People often think that clinical psychology, being a “touchy feely” subject, would be one for qualitative methods but psychologists are very good at putting numbers to feelings. Suppose that they wanted to assess how patients felt after a course of treatment such as cognitive and behavioural therapy. They could give a questionnaire along the following lines:

  1. Since my course I feel more self-confident
  2. Since my course I feel more in control of my life

Please tick the one answer that you think most appropriately describes the following statements in relation to you.

The options to mark may be:

  1. Strongly agree
  2. Slightly agree
  3. Neither agree nor disagree
  4. Slightly disagree
  5. Strongly disagree

The responses may then be marked from 1 to 5 or 0 to 4 and this gives a numerical way to grade the response.

Where Numbers Cannot Help

However, this does not allow issues to be probed further. There can be no one who was born since the mid-1940s who can claim to have started smoking without knowing of the dangers. Why do people still do it? Why do people who smoke not give it up? Addiction is important.1Smokers: why do they start–and continue? It would be possible to ask them to assess statements such as “I am put off smoking by the health warnings on cigarette packets” and get them to rate the statement as above. However, that does not allow further probing such as, “If you are influenced, why do you not give up?” or “Why do you not believe that the warning applies to you?” There is obviously considerable social status or kudos that some people believe they can achieve by smoking. Perhaps they intend to give up when they get older. How much damage do they think that they will have done to their bodies by then?

These are often called structured or semi-structured interviews as they are not a chat that may go off in any direction. Children start to smoke at an early age and peer pressure is important.2When and why children first start to smoke? Friends are an important determinant of starting smoking.3Determinants of smoking initiation among women in five European countries When I did a PubMed search I was surprised at how few articles there were on this very important subject.

Which door would you choose and why would you choose it?

The United Kingdom has or had the second worst rate of teenage pregnancy in the developed world, behind the United States.4A League Table of Teenage Births in Rich Nations This report is from 2001 and things may have improved more recently. Why do we do so much worse than our neighbours in Europe? When contraception is so readily available why is it so often not used? This is very important but there is a remarkable paucity of good quality evidence. However, things do seem to be improving. At the end of 2019, The Times announced that teenage pregnancy rates halved within the past decade after a successful long-term public health campaign.5Decade in Review: Reasons to be Cheerful The most recent figures showed that 16,740 girls aged below 18 became pregnant in 2017 compared with 18,086 the previous year. This was an annual fall of 7.4% and a 61.1% decline since 2007. The conception rate for girls under 18 in England and Wales had fallen for 10 consecutive years. In 2007 there were 41.6 conceptions per 1,000 girls aged 15 to 17, but by 2017 this had dropped to 17.9 pregnancies per 1,000 teenage girls.

They added that unplanned teenage pregnancies are strongly linked to educational underachievement for women and child poverty. A plan to cut teenage pregnancy rates was introduced by Tony Blair’s government in 1999 and included offering girls education on sex and relationships and contraceptives in clinics with a non-judgmental approach by health staff. By 1999, I did not think that the non-judgmental approach was anything new. It must be practical rather than moralistic.

It is usually done by interviews but questionnaires can be used

The main methods employed in qualitative research are observation, interviews, and documentary analysis. Observation aims to be as unobtrusive as possible so as not to disturb the natural environment that is being observed. Interviews can be unstructured and part of an apparently informal conversation. The interviewer has to win the confidence of the person he is interviewing and not to try to impose his will on that person. Documentary analysis may involve looking at video recordings. An excellent example is the work of Dr David Pendleton, a social psychologist rather than a medical doctor, but he did a great deal of work on analysing the content of the GP consultation for his PhD thesis. This was based on video recordings of GP consultations. He worked closely with a number of GPs in the Oxford region and the result has had enormous influence on the training of doctors, especially in general practice.6Consultation analysis. This website is designed for doctors but it may still be interesting.

Questionnaires have to be validated and development and validation is not easy. There is often a belief that anyone can concoct their own questionnaire and that this can be the basis of qualitative research. This is untrue. It may be possible to get an “off the shelf” questionnaire that someone else has validated. In the chapter on controlled trials, pain assessment techniques were described. They also have to be validated.

Why We Need Qualitative Research

Qualitative work, done well, is not a soft option for those who wish to do research. Perusal of the medical literature shows many RCTs along with meta-analysis and systematic reviews. Our knowledge of “does it work” is very good. There is less on cohort studies as may be expected as they can take years to perform but what is there is often of very good quality. They have provided a great deal of valuable knowledge. Qualitative work is very much in the minority. It does exist but the volume is much poorer than in other fields.

Why do people ignore clear danger?

There is much that we know about healthy living and the avoidance of disease but people choose to ignore it. Why do they ignore it? The paucity of information about why people smoke has been noted but we need to understand it more to be able to influence behaviour. Binge drinking and regular drinking to excess still occurs. Why do teenagers have unprotected sex and then wonder why they get pregnant? When the addict started to use heroin did he really think that he was the one who could just take it up and leave it at will? People ignore advice about a healthy diet and about vaccination. They seem more impressed by celebrity endorsement than by scientific advice. People get symptoms of serious illness yet they refuse to go to their doctor until it is quite advanced. Everyone knows that cancer is most treatable if caught early. The rationale behind these conundrums is fertile ground for qualitative research.

Why do people miss appointments?

In 2019, a paper in the British Journal of General Practice was a qualitative examination of why some patients who have been referred to hospital with a diagnosis of possible or probably cancer, fail to attend. In-depth, individual interviews were undertaken face-to-face or by telephone, followed by thematic framework analysis. The analysis and implications are too extensive to give but the article is available in full, free online.7Non-attendance at urgent referral appointments for suspected cancer

When I was being investigated for prostate cancer, there were many steps and each was done within the target of two weeks from the last step. I was told that the exception may be the radio-isotope bone scan as there had been some technical problem with the machine but it had been fixed. I was sent an appointment for a little over a fortnight but the next day I received a telephone call from a secretary in the department who said that there had been a cancellation for the following day. “I don’t suppose you would like to come,” she said, sounding desperate. “You bet I would!” It knocked about two weeks off my time to investigation and hence time to start treatment. I spoke to a radiographer when I attended who said that they were under great pressure to fill all slots, as I can understand, but the secretary had had enormous difficulty finding someone who wanted to come in early. I was amazed but glad she had called me.

I have a friend who used to work in the breast screening department of our local hospital and she said that she would often have to telephone women who had had a positive mammogram to offer them an appointment to see the consultant in a few days but they would often decline with such excuses as having lunch with their friend that day. I would have thought that a diagnosis of “cancer until proved otherwise” is the utmost priority and takes precedence over all other appointments. It needs to be sorted out as soon as possible. Why do other people not think the same? Do they not understand or are they in denial?

Why do we make the choices we do?

There is a gradient of life expectancy through the social classes. The professional classes live, on average, about five years longer than the unskilled classes. Much of this is due to poor lifestyle and presenting late with diseases. Across the social classes, women live on average five years longer than men although this figure may be nearer two years nowadays. Some of this is biological and not amenable to change but much is related to risk taking, poor lifestyle and late presentation of disease. Men are reluctant to go to the doctor. We cannot change it until we understand it.

There is still a great deal of research to be done to elucidate why knowledge is not reflected in practice and why people take unnecessary risks in their lives. Qualitative research may be the poor relation but we need much more good quality work to be able to implement the knowledge we already have.

Further Reading

References

  1. Chapman S. Smokers: why do they start–and continue? World Health Forum. 1995;16(1):1-9; discussion 10-27. PMID:7873017
    http://www.ncbi.nlm.nih.gov/pubmed/7873017
  2. Swan AV, Creeser R, Murray M. When and why children first start to smoke. Int J Epidemiol. 1990 Jun;19(2):323-30.
    http://www.ncbi.nlm.nih.gov/pubmed/2376442
  3. Oh DL, Heck JE, Dresler C, Allwright S, Haglund M, Del Mazo SS, Kralikova E, Stucker I, Tamang E, Gritz ER, Hashibe M. BMC Public Health. 2010 Feb 17;10:74. PMID:20163736. Determinants of smoking initiation among women in five European countries.[full text]
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2833141/
  4. UNICEF Innocenti Research Centre. A League Table of Teenage Births in Rich Nations.
    https://www.unicef-irc.org/publications/pdf/repcard3e.pdf
  5. Reasons to be cheerful: Alexa’s arrival, cancer survival and a beaver revival. The Times. 1 January 2020.
    https://www.thetimes.co.uk/edition/news/reasons-to-be-cheerful-alexas-arrival-cancer-survival-and-a-beaver-revival-zfkxvjzlt
  6. Tidy C. Consultation analysis. EMIS 2014. (Designed for doctors)
    http://www.patient.co.uk/doctor/Consultation-Analysis.htm
  7. Jefferson L, Atkin K, Sheridan R, Oliver S, Macleod U, Hall G, et al. Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs. British Journal of General Practice 2019; 69 (689): e850-e859 [full text]
    https://bjgp.org/content/69/689/e850

Site Index

This website is under construction although nearing completion. The following list shows the sections that are planned but, so far, only the ones in blue have been completed. Just click on the topic in blue to go to that part of the site.

1 Introduction
2 A Very Brief History of Science And Medicine
Fundamentals of Medical Science
3 Finding Good Medical Advice and Evidence Based Medicine
4 Randomised Controlled Trials
5 Cohort or Longitudinal and Epidemiological Studies
6 Qualitative Research
7 Basic Maths in Medical Research and Decision Making
8 How Good is the Evidence?
9 Ethics in Practice and Research
Public Health Issues
10 Screening Programmes
11 Fake News and Vaccine Scares
12 Electronic Cigarettes (E-Cigarettes)
13 Motor Vehicle Emissions, Air Pollution and Health
14 COVID-19. What You Need to Know
15 What we Must Learn from the COVID-19 Pandemic
Nutrition
16 Basics of Nutrition
17 Exercise, Obesity and Diets for Weight Loss
18 Diets and Nutrition for Health and Fitness
19 Supplements
Complementary and Alternative Medicine
20 Introduction to Alternative Healthcare
21 Homeopathy
22 Acupuncture
23 Manipulation of the Spine
24 Reflexology
25 Herbal Remedies
26 Other Natural Products
27 Chelation Therapy
28 Hypnosis
29 Other Modalities of Complementary and Alternative Medicine
Some Controversial Diseases
30 Fibromyalgia
31 Chronic Fatigue Syndrome (CFS) or Myalgic Encephalitis (ME)
32 Systemic Candidiasis and Leaky Gut Syndrome
33 Mobile Phones, Masts, Wi-Fi and Electro-sensitivity
The Environment
34 Global Warming and Climate Change
35 Alternative Energy
Some Final Thoughts
36 Still Searching for the Age of Reason