Aim

Provide a description of which research questions are suitable for a qualitative approach, the different qualitative data collection methods and the most important features of qualitative research.

Description

Qualitative research methods are increasingly being used within medical research; a trend that is also being observed within the EMGO Institute. Occasionally only qualitative data collection methods are used in studies, but more often a combination of quantitative and qualitative methods are used. (In-depth) interviews in particular frequently occur as preparation for or a supplement to a quantitative study. A global description of which research questions are suitable for a qualitative approach, the different qualitative data collection methods and the most important features of qualitative research is provided below.

Which research questions demand a qualitative approach?
Qualitative research methods are particularly appropriate if:

• You don’t know very much about a topic (exploratory research);
• You are interested in the nature of the phenomenon (in contrast to the aspects);
• You are interested in the respondents' experiences;
• You want to study the meaning of interactions, processes, behaviours, feelings, attitudes and experiences;
• There are conflicting outcomes between different studies or the outcomes require a different explanation;
• The subject is difficult to approach as a quantitative study for practical or ethical reasons.

What types of qualitative methods are there?
Three fundamental methods can be distinguished for qualitative research, within which there is variation in implementation. A choice can be made to use a single method, although various methods can also be combined within a project (methodological triangulation).
The three fundamental methods are:

• Observation

This can be done by (intensively) participating in the field you wish to study (participatory observation/emphasis on participation), or by being present in the field and making observations (observational participation/emphasis on observation).

• Interviewing

Various types of interviewing can be employed, depending on the research question and level of exploration. A distinction is made here between:

• The level of interview structure

Open interview/in-depth interview, semi-structured interview, structured interview. Often a list of themes (topic list) is used, which can be strictly followed to a greater or lesser extent.

• Single or repeated interviews
• Individual or group interviews (focus groups)

Interaction between participants is central to focus groups. Participants are stimulated by others’ ideas and will form their own opinion, or modify their opinion having listened to others’ accounts (Assema, 1992). As participants are able to ask each other questions and explain themselves to others, a focus group can produce more than the sum of the individual interviews.

• Document analysis

This may involve personal as well as non-personal documents (letters, diaries, photos, archive, reports of meetings, newspaper articles, film, drawings, etc.). Documents are used, in particular, for historical research.

General principle:
Use observation if you want to know how people behave in practice. You interviews if you are interested in opinions/experiences/attitudes.

Important features of qualitative research
- Data collection and analysis take place simultaneously (iterative process).
In contrast to quantitative research, in qualitative research it can be difficult to draw a clear line between the data collection and analysis phases. Both phases take place simultaneously and the researcher can also go back to the previous phase. A feature of this is that the analysis of the material starts as soon as the first data have been collected. In a way, this analysis guides subsequent data collection. The researcher starts off with a few global insights that provide an initial directional guide and that are adapted to the situation in the field of study in the course of the research process. Having first become “openly” acquainted with the field, insights are provided into the important focus points for the research questions, and finally focused work can be undertaken using the specific research questions.

- In contrast to quantitative research, the recruitment of respondents/patients in qualitative research is not aimed at generalisation: Concepts such as “randomisation” or “random selection” do not play a role here. Instead, researchers strive towards theoretical saturation: “inclusion” continues until a point is reached where there is a sense that sufficient insight has been acquired about the research phenomenon. Important principles in this process are constant comparison, purposive sampling and theoretical sampling: The researcher is constantly looking for new “cases” that are able to sharpen up, confirm or correct earlier cases (Wester, 1987). This results in the research group usually being relatively small (maximum of tens of participants) and heterogeneous instead of large group size and (particularly for subgroups) homogeneous, as is often the case for quantitative research.

- Checks on the quality of the data can be assessed in a number of ways for qualitative research. Two important principles here are the so-called “member check” and “peer debriefing”. Member check = researcher checks his interpretation with the participants for instance by restating or summarizing information and then question the participant to determine accuracy or by sharing all the findings with participants at the end of the data-collection Peer debriefing = having fellow researchers check interpretations.

Publication
Publication of qualitative research within medical science is occurring more and more frequently. Certain criteria are imposed on publishing qualitative research. The British Medical Journal has created a checklist with its own set of criteria for reporting qualitative research: Qualitative research checklist (British Medical Journal).
This checklist is also useful if you want to publish in another journal. Examples of articles based on qualitative data have been included in the quality assurance handbook with this guideline.

AMC Guideline
For a guide to qualitative research take a look at Guidelines for safeguarding quality in health(care) research:Qualitative research (Richtlijnen voor kwaliteitsborging in gezondheids(zorg)onderzoek: kwalitatief onderzoek),which was published in 2002 by the Netwerk Kwalitatief Onderzoek (Qualitative Research Network) AMC-UvA for the AmCOGG (Amsterdams Centrum voor Onderzoek naar Gezondheid en Gezondheidszorg, Amsterdam Centre for Health & Healthcare Research), which can be found in the quality assurance handbook with this guide.
This is a comprehensive checklist describing aspects you need to think about when designing and implementing (qualitative) research in the AMC. Informative/relevant sections specific to the design and implementation of qualitative research by researchers at the EMGO+ Institute are:

• Introduction
• Paragraph 1b regarding the research question
• Paragraph 2 about the research design
• Paragraph 3a, 3c and 3f about data collection, data entry and data analysis

Analysis programmes
There are various software programmes that support the analysis of qualitative data, such as KWALITAN, NVivo and Atlas.ti. Programmes like these can be a useful tool in ordering the data, although you will need to order the data yourself.
The Atlas.ti programme has been acquired for analyses in the EMGO Institute in August 2006. The programme can be installed via: M:\program\atlas.ti\setup.exe. Enter emgo for the user name and leave the organisation name blank!
The serial number is in the readme.txt file in the folder: M:\program\atlas.ti. Make sure you don’t select the LAN installation and therefore deselect the relevant box. Courses in Atlas.ti can be followed at KWALON, a platform for qualitative research (see under “courses”).

The following books, websites and courses are recommended:
Additions are welcome; please contact the Quality Committee.

Basic books on qualitative research:

• D.B. Baarda, M.P.M. de Goede, J. Teunissen. Basisboek kwalitatief onderzoek. Praktische handleiding voor het opzetten en uitvoeren van kwalitatief onderzoek (Basic qualitative research: Practical guide for design and conducting qualitative research). Wolters-Noordhoff bv Groningen/Houten, 2001. ISBN: 90 207 2485 1
• Hennie Boeije. Analyseren in kwalitatief onderzoek. Denken en doen (Analysing qualitative research: Thinking & doing). Boom onderwijs, 2005. ISBN:90 8506078 8
• Wester, F. Strategieën voor kwalitatief onderzoek (Strategies for qualitative research). Coutinho, Muiderberg, 1987. ISBN: 90-6283-896-0

Books/articles (specific to) qualitative research methods:

• Gubrium JF, Holstein JA (eds). Handbook of Interview Research. London: Sage 2002.
• Pope C, Mays N. (eds) Qualitative Research in Health Care. Second edition. BMJ books 2000. ISBN: 0-7279-1396-4 (A collection of BMJ articles on qualitative research in general and specific data collection methods).
• Strauss A, Corbin J. (eds.) Grounded Theory in Practice. London: Sage 1997.
• Yin R.K. Case study research. Design and methods London: Sage 1989.
• Assema P van, Mesters I, Kok G. Het focusgroep-interview: een stappenplan (Focus group interviews: A stepwise approach). TSG 1992;70:431-437
• Series of 4 articles about qualitative research methods in Huisarts & Wetenschap (General Practitioners & Science):
• Philipsen H, Vernooy-Dassen M. Kwalitatief onderzoek: nuttig, onmisbaar en uitdagend (Qualitative research: Useful, essential and challenging). Huisarts & Wetenschap (General Practitioner & Science) 2004;47(10): 454-457
• Hak T. Waarnemingsmethoden in kwalitatief onderzoek (Observations in qualitative research). Huisarts & Wetenschap (General Practitioner & Science) 2004;47(11): 502-508
• Wester F. Analyse van kwalitatief onderzoeksmateriaal (Analysing qualitative research material). Huisarts & Wetenschap (General Practitioner & Science) 2004;47(12): 565-570
• Zwieten M van, Willems D. Waardering van kwalitatief onderzoek (Evaluating qualitative research). Huisarts & Wetenschap (General Practitioner & Science) 2004;47(13): 631-635

Websites:

• www.kwalon.nl

The KWALON platform is an association that aims to develop and disseminate qualitative methods in behavioural and social science research.

Courses:

• KWALON offers various courses in qualitative research (including specific data collection methods and data analysis programmes, as well as an introductory course in qualitative research).
• CaRe Netherlands School of Primary Care Research also offers a course in “Qualitative research methods in health care” (S08).

V1.2: 1 Dec 2011: Removal of link kwalitatief sterk
V1.1: 1 Jan 2010: English translation.
V1.0: 23 Nov 2006: Draft version has been rewritten in full.

1. Which research method(s) have been used? Has triangulation been used?
2. How have patients/respondents been selected?
3. How was theoretical saturation employed? Has purposive sampling been used? If so, please provide an accurate description of the procedure.
4. Have there been quality checks on the data through a member check or peer debriefing?
5. Has the patients/respondents’ anonymity been safeguarded? If so, how?
6. How has the information obtained been recorded? Have various memos been used?
7. Has the role of the researcher in the data collection process been determined and described? If so, how?
8. How have the available data been analysed?
9. Describe the strategy for the publication of results. Have or will the BMJ guidelines be used?