Qualitative Questions 19961

Qualitative Questions 19961
Qualitative Questions 19961
Qualitative Questions 19961
Qualitative Questions 19961
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    Family Practice© Oxford University Press 1996 Vol.  13, Suppl. 1Printed in Great Britain

    Qualitative research: the research questions it canhelp answer, the methods it uses, the assumptionsbehind the research questions and what influencesthe direction of research.A summary of the panel discussion at theconference Exploring qualitative research ingeneral practice Frances Griffiths This pape r describes the themes identified by the editorfrom the recording and transcripts of the panel discus- sion at the conference  Exploring qualitative researchin general practice.  The editing process was a form ofqualitative analysis in itself The panel discussion wasbased on research questions developed by groups of con-ference participants during the conference lunch b reak.The research questions were selected for discussion bythe panel chairman and panel members. The panel con-sisted of the conference speakers (DA, SH, MJ, CH,RJ) and chairman (MM) with other conference par-ticipants contributing comments (one contributor couldnot be identified from the recording). In this paper thediscussion points made are attributed to the personspeaking by initials following their comment. The text does not represent exact quotations but the editor hasendeavoured to preserve the essence and meaning ofthe comments (FG).One criterion used in the selection of topics for discu s-sion was w hether the group of participants had produceda question. T he panel decided to respond only to ques-tions. We are programmed to look at research asquestions but is research only about questions? (SH).

    Research questions that qualitativemethods can help answer Qualitative methods may provide useful tools forunderstanding phenomenon for which, at present, wehave no really good working models, for example, whypeople do not take prescribed drugs as intended by thedoctor (MM ). 'Wh y' questions such as W hy do GPsnot implement evidence-based guid elines? are best ap-

    Norton Medical Centre, Harland House, Norton, Stockton-on-TeesTS20 IAN, UK.

    proached with a qualitative method (DA), but 'what'ques t ions such as W ha t a re evidence-based guid elines? may also use qualitative methods (SH).People may say that evidence-based guidelines are agood thing but act differently. To start making senseof that we need to ask doctors  'What do you mean byevid enc e? The behaviour of GPs may be based mo reon the evidence of their own expe rience which is a dif-ferent notion of evidence from that used in guidelines(CH ). A research question such as W ha t precipitatespeople to present to their GP saying they are tired allthe tim e? raises other questions: W ha t does tirednessme an? A re people more tired now than they we re?H as the meaning of tiredness ch ang ed ? (SH). Theresearch question W hat does drug-seeking behaviour really me an ? is a different ord er of question as it istrying to find out what drug-seeking behaviour meansin a particular culture or society, rather like asking  W hat does going to church m ea n? It is a sociologicalor anthropological question which cannot be answeredby simply interviewing people. Developing an answerwould involve starting from a particular theoreticalperspective (e.g. Marxism or psychoanalysis) whichmay provide some insights, then finding a way of testingthese out (DA). It is possible ask individuals W hatdoes this mean to yo u? The answers may be expres-sions of the bigger scheme or the individuals may giveinteresting idiosyncratic answers of their own. These answers only make sense against a backgroun d of thethemes in society at the time, and those you have todiscover by looking at the media, analysing newspapers,etc.  (CH ). To begin to answer the question D o pa-tients and GPs both want the same thing out of generalpra ctic e? , the.different m eanings and assumptions oftwo grou ps in society, doctors and patients, would haveto be investigated . The question indicates the clash oftwo cultures but we do not know enough about them,it would be complex to investigate and the question asphrased is probably too big to get started (CH).

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    Family Practice—an international journal Methods used in qualitative research A resea rch qu estion can be looked at from differentangles and using different methods to provide differenttypes of answer. This notion of triangulation can resultin stronger and better research tools (MM). The dif-ferent methods may be qualitative, quantitative or a mix-ture . A po pulation survey may reveal the frequency of a symptom such as tiredness and how many peopleconsult their doctor about it. To understand why som epeople go to see their doctor and others do not, someof those that attend the doctor and some that do not couldbe interviewed (RJ).

    An interview study can take many forms. O ne of thecommonest used is the semi-structured interview wherethe interviewer h as a schedule of areas to cover. Inter-views of do ctors about evidence-based guidelines mayinc lude H av e you heard of evidence-basedguid elines? D o you know what in your clinical prac-tice is based on evi den ce? D o you apply guidelines,when and wh ere ? (DA ). However, if the interview subjects are GPs, can a GP be the interviewer? Oneview is that you cannot study your own tribe becausethere is too much hidden culture and assumptions. Th eresearcher needs to ask innocent questions to uncoverthis. H owev er, there can be good and bad interviewersfrom all disciplines, it is partly a question of techni-que.  A GP interviewing GPs will give a different in-terview and get a different story from a social scientistinterviewer, but who is to say that one story is goingto be more interesting or rewarding than the other?(CH) .

    There are specific techniques that can be used withininterviews to enhance the research data. For example, a research q uestion about b eing tired all the time is using,what is know as standardized language of distress. Allof life's problems from unemployment to marital prob-lems come in the phrase 'tired all the time'. To workoutward s from this label you could use free-association,asking question such as ' 'W hat do you mean by tired?''' 'W hat do you mean by all the time? ''Wh at do peoplewho are not tired look like ? When looking at any con-dition it can be very revealing to ask about the exactoppo site. If you ask someone taking diazepam W hateffect does diazepam have on you when you take it?the reply may be O h it does not have any effect .Asking W ha t would happen if you did not havedia zep am ? would give a different series of answ ers.A different technique could b e used for a research ques-tion, such as W ha t are the images which GP s haveof themselves and their role s? If you ask a doctor' 'H ow do you see your ro le? they are likely to freezeup as the question is so open-ended. One way aroundthis would be using projective techniques. You couldgive them a series of scenarios , each one a descriptionof what a G P do es, and ask them which they most iden-tify with, or give them a story of a GP and ask themto tell you about the doctor written about in the story.

    This way the person interviewed can be more relaxedas they are not talking about them selves but projectingonto the story (CH). Interviews have to aim at findingout about things that are accessible to the person inter-viewed. If you asked a GP W ha t do you want fromgeneral practice? you might get a public or pat answer,but it would be too general to be of value in the research. The question would have to be broken dow n as you canonly find out what people can make sense of themselves(DA).A group interview could be used to develop, for ex-ample, a list of priorities for quality standards in generalpractice. The results from a group of GPs and a groupof patients could be compared to see how much theymatch (RJ). A Balint group is a special form of groupresearch which could look at when and why doctorsfollow evidence-based guidelines or not, and tease outsome of the detail of this. Being from a differentdiscipline, the psychoanalyst in the Balint group has theimportant role of heightening perception and observa-tion to help the group see what is at that moment beyondthe field of vision (SH).

    Observational studies can reveal the reality behindthe rhetoric. For exam ple a research question about theprimary health care team may see the team as a groupof professionals co-operating with each other. However,the members of the team come from a number of dif-ferent professional subcu ltures. It w ould be interestingto do a flynon-the-wall observation to see how thingsactually worked (CH). Written material has been mentioned as a source ofdata about the prevailing c ulture. In trying to answ era research question such as 'What does tiredness mean?'in a literate society, looking at printed material suchas newspapers and wo men 's m agazines is important inrevealing the wider cultural themes. Doing this revealsa who le series of so-called d epletion diseases based onmechanical metaphor such as 'running on empty' 'ata low ebb' 'drained' (CH). The historical study of aquestion about a symptom such as tiredness may usea series of medical texts, of which th ere are many fromthe eighteenth century on ward s. A historian m ight lookat the way words are used in certain contexts such asfatigue, as used by a psychiatrist or a pathologist.Newspapers and personal diaries or correspondence,if available, can also be used. However, historians arewary of seeing continuity in the use of, for example,

    diagnoses over time. To use the example of learningdifficulties, historians would argue that it is difficultto be sure whether a diagnosis based on a number ofsymptoms made in the nineteenth century, such asfeeble-mindedness, is the sam e