Qualitative research in medicine and health care: questions and controversy

Preference Sensitive Care and Shared Decision-Making in Lumbar Spinal Stenosis: A Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVE

The objective of this study was to conduct a scoping review exploring the extent to which preference sensitivity has been studied in treatment decisions for lumbar spinal stenosis (LSS), utilizing shared decision-making (SDM) as a proxy.

BACKGROUND

Preference-sensitive care involves situations where multiple treatment options exist with significant tradeoffs in cost, outcome, recovery time, and quality of life. LSS has gained research focus as a preference-sensitive care scenario.

MATERIALS AND METHODS

A scoping review protocol in accordance with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews" regulations was registered with the Open Science Framework (ID: 9ewup) and conducted across multiple databases from January 2000 to October 2022. Study selection and characterization were performed by 3 independent reviewers and an unbiased moderator.

RESULTS

The search resulted in the inclusion of 16 studies varying in design and sample size, with most published between 2016 and 2021. The studies examined variables related to SDM, patient preferences, surgeon preferences, and decision aids (DAs). The outcomes assessed included treatment choice, patient satisfaction, and patient understanding. Several studies reported that SDM influenced treatment choice and patient satisfaction, while the impact on patient understanding was less clear. DAs were used in some studies to facilitate SDM.

CONCLUSION

The scoping review identified a gap in comprehensive studies analyzing the preference sensitivity of treatment for LSS and the role of DAs. Further research is needed to better understand the impact of patient preferences on treatment decisions and the effectiveness of DAs in LSS care. This review provides a foundation for future research in preference-sensitive care and SDM in the context of lumbar stenosis treatment.

Canadian Kidney Transplant Professionals' Perspectives on Precision Medicine and Molecular Matching in Kidney Allocation

Background

Antibody-mediated rejection is an important cause of kidney transplant loss. A new strategy requiring application of precision medicine tools in transplantation considers molecular compatibility between donors and recipients and holds the promise of improved immunologic risk, preventing rejection and premature graft loss. The objective of this study was to gather Canadian transplant professionals' perspectives on molecular compatibility in kidney transplantation.

Methods

Seventeen Canadian transplant professionals (14 nephrologists, 2 nurses, and 1 surgeon) participated in semistructured interviews in 2021. The interviews were digitally recorded, transcribed, and analyzed using the qualitative description approach.

Results

Participants identified fair access to transplantation as the most important principle in kidney allocation. Molecular compatibility was viewed as a promising innovation. However, participants were concerned about increased waiting times, negative impact on some patients, and potential problems related to the adequacy of information explaining this new technology. To mitigate the challenges associated with molecular matching, participants suggested integrating a maximum waiting time for molecular-matched kidneys and expanding the program nationally/internationally.

Conclusions

Molecular matching in kidney transplantation is viewed as a promising technology for decreasing the incidence of antibody-mediated rejection and improving graft survival. Further studies are needed to determine how to ethically integrate this technology into the kidney allocation algorithm.

Lived Experiences of Hemodialysis Health Care Workers during the COVID-19 Pandemic: A Qualitative Study from the Quebec Renal Network

Key Points

Hemodialysis workers' well-being and work were affected by the COVID-19 pandemics. Effective communication strategies and taking into account psychological distress are ways to mitigate the challenges faced by health care workers.

Background

The COVID-19 pandemic has disrupted health systems and created numerous challenges in hospitals worldwide for patients and health care workers (HCWs). Hemodialysis centers are at risk of COVID-19 outbreaks given the difficulty of maintaining social distancing and the fact that hemodialysis patients are at higher risk of being infected with COVID-19. During the COVID-19 pandemic, HCWs have had to face many challenges and stressors. Our study was designed to gain HCWs' perspectives on their experiences of the impacts of the COVID-19 pandemic in hemodialysis units.

Methods

Semistructured interviews were conducted with 22 HCWs (nurses, nephrologists, pharmacists, social workers, patient attendants, and security agents) working in five hemodialysis centers in Montreal, between November 2020 and May 2021. The content of the interviews was analyzed using thematic analysis.

Results

Four themes were identified during the interviews. The first was the impact of COVID-19 on work organization, regarding which participants reported an increased workload, a need for a consistent information strategy, and positive innovations such as telemedicine. The second theme was challenges associated with communicating and caring for dialysis patients during the pandemic. The third theme was psychological distress experienced by hemodialysis staff and the psychosocial impact of COVID-19 on their personal lives. The fourth theme was recommendations made by participants for future public health emergencies, such as maintaining public health measures, ensuring an adequate supply of protective equipment, and developing a consistent communication strategy.

Conclusions

During the first and second waves of the COVID-19 pandemic, HCWs working in hemodialysis units faced multiple challenges that affected their well-being and their work. To minimize challenges for HCWs in hemodialysis during a future pandemic, the health care system should provide an adequate supply of protective equipment, develop effective communication strategies, and take into account the psychological distress related to HCWs' professional and personal lives.

Use of Framework Matrix and Thematic Coding Methods in Qualitative Analysis for mHealth: NIRUDAK Study Data

Objective

Framework Matrix Analysis (FMA) and Applied Thematic Analysis (ATA) are qualitative methods that have not been as widely used/cited compared to content analysis or grounded theory. This paper compares methods of FMA with ATA for mobile health (mHealth) research. The same qualitative data were analyzed separately, using each methodology. The methods, utility, and results of each are compared, and recommendations made for their effective use.

Methods

Formative qualitative data were collected in eight focus group discussions with physicians and nurses from three hospitals in Bangladesh. Focus groups were conducted via video conference in the local language, Bangla, and audio recorded. Audio recordings were used to complete a FMA of participants' opinions about key features of a novel mHealth application (app) designed to support clinical management in patients with acute diarrhea. The resulting framework matrix was shared with the app design team and used to guide iterative development of the product for a validation study of the app. Subsequently, focus group audio recordings were transcribed in Bangla then translated into English for ATA; transcripts and codes were entered into NVivo qualitative analysis software. Code summaries and thematic memos explored the clinical utility of the mHealth app including clinicians' attitudes about using this decision support tool.

Results

Each of the two methods contributes differently to the research goal and have different implications for an mHealth research timeline. Recommendations for the effective use of each method in app development include: using FMA for data reduction where specific outcomes are needed to make programming and design decisions and using ATA to capture the more nuanced issues that guide use, product implementation, training, and workflow.

Conclusions

By describing how both analytical methods were used in this context, this paper provides guidance and an illustration for use of these two methods, specifically in mHealth design.

Perspectives of Kidney Transplant Recipients, Transplant Candidates, and Living Kidney Donors on the Role of Patients’ Self-Narratives and Experiences of Creative Writing Workshops: A Qualitative Study

Background:

Kidney transplantation is the best treatment for kidney failure but is associated with medical, psychological, and existential challenges for patients. Patients’ experiential knowledge can help other patients facing these challenges. Patients’ self-narratives and creative writings are ways to operationalize this experiential knowledge. Creative writing has been described as a therapeutic tool for patients with chronic disease. Over the past year, we conducted creative writing workshops with kidney transplant recipients (KTRs), living kidney donors (LKDs), kidney transplant candidates (KTCs), and professional writers. During these workshops, patients were invited to explore different aspects of their experiences of their transplant or donation journey through narrative-writing, poetry, comic art, and screenwriting.

Objective:

The objectives of this study were to gather the perspectives of KTRs, KTCs, and LKDs on the role of patients’ self-narratives and creative writing, and to collect patients’ experiences of the creative writing workshops.

Design:

Focus groups and individual interviews.

Setting:

The Center hospitalier de l’Université de Montréal (CHUM) kidney transplant program.

Participants:

KTRs, LKDs, and KTCs attending the CHUM kidney transplant clinic between February 2020 and January 2021.

Methods:

We conducted 2 focus groups and 8 semi-structured individual interviews with 7 KTRs, 8 LKDs, and 5 KTCs from the CHUM between June and November 2020, before the creative writing workshops. We also conducted 10 semi-structured interviews with 5 KTRs, 1 KTC, and 4 LKDs in March 2021, after their participation in the creative writing workshops. The interviews were recorded and transcribed. Thematic and content analyses were conducted.

Results:

KTRs, LKDs, and KTCs had multiple significant moments to share from their transplant/donation journey. These moments were highly emotional and marked by uncertainty. The creative writing workshops were described as therapeutic by participants, because they offered a safe space for group-facilitated reflection, including a discovery and learning process, and normalization, relativization, and appreciation of the transplant/donation experience. The creative writing workshops also provided an opportunity to give back to others (helping other patients, promoting kidney donation and continuing this process in the future through the web platform).

Limitations:

Our participants came from a single French-speaking urban transplant center in Quebec and were highly educated.

Conclusion:

The study set out to capture the perspectives of KTRs, LKDs, and KTCs through the sharing of self-narratives and their participation in creative writing workshops related to their transplant or donation journey. A website was set up to publish patients’ creative writings (https://recitsdudonetdelavie.lorganon.ca/les-recits/). Further study is needed to assess the website’s impact on other patients.

Trial registration:

Not registered.

Compatible Donor and Recipient Pairs' Perspectives on Participation in Kidney Paired Donation Programs: A Mixed-Methods Study

Background:

Compatible pair participation in kidney paired donation (KPD) may increase the likelihood of finding suitable matches for all registered pairs. Retrospective studies have shown variable enthusiasm for participating in KPD in compatible pairs.

Objective:

The study objective was to gather potential living donor (PLD) and transplant candidate (TC) perspectives on compatible pair participation in KPD.

Design:

Surveys and qualitative interviews.

Setting:

Three transplant programs in Canada: Centre hospitalier de l’Université de Montréal in Montreal (Québec), Vancouver General Hospital, and St. Paul’s Hospital in Vancouver (British Columbia).

Patients:

Both PLDs and TCs undergoing evaluation for donation/transplantation between 2016 and 2018 at 3 transplant programs in Canada.

Methods:

Descriptive statistical analysis was performed for the results of the survey and thematic and content analysis method was used for the content of the qualitative interviews.

Results:

A total of 116 PLDs and 111 TCs completed surveys and an additional 18 PLDs and 17 TCs underwent semi-directed interviews. Of those surveyed, 61.2% of PLDs and 76.6% of TCs reported a willingness to participate in KPD as a compatible pair. The possibility of a more optimally matched kidney for the TC and policies ensuring prioritization of the TC for repeat transplantation in the event of early graft failure increased willingness to participate in KPD. Major concerns expressed during the interviews included the desire to retain the emotional bond of directed donation, the fear of chain breaks or donor reneging, delays in transplantation, and additional travel associated with participation in KPD.

Limitation:

The limitations of this study are that it was conducted in only 3 Canadian transplant programs and that the interviews and surveys were in French and in English. As a consequence, the results may not be reflective of the views of individuals not living in these 2 provinces and from ethnic minority populations.

Conclusion:

Most of the compatible PLDs and TCs surveyed were willing to participate in KPD. Ensuring timely transplantation and a more optimal match for TCs and offering a policy of reciprocity to ensure timely repeat transplantation for compatible recipients if their allograft fails post KPD transplant may further increase compatible pair participation in KPD.

A Qualitative Study of Patient Themes for the Quality of the Total Joint Arthroplasty Experience

Patients have limited involvement in the development of quality measures that address the experience of undergoing total joint arthroplasty (TJA). Current quality measures may not fully assess the aspects of care that are important to patients. The goal of this study was to understand quality of care in TJA from the patient perspective by exploring patients' knowledge gaps, experiences, and goals. The authors completed a prospective qualitative analysis of patients who had undergone hip or knee TJA. Patients completed an open-ended, structured questionnaire about the surgical and recovery process as it relates to quality of care. The authors used a phenomenologic approach and purposeful sampling to enroll 74 patients 6 to 8 weeks after TJA. Responses underwent thematic analysis. Codes were used to identify themes that were important to patients in quality of care in TJA. The authors identified 3 themes: (1) returning to activity without pain or complication, which included psychological, functional, and complication-related goals; (2) negotiating the physical and psychological challenges of recovery, which encompassed the need for assistance from the caregiver as well as psychological and physical barriers to recovery; and (3) being prepared and informed for the process of surgery, including physical, logistical, and psychological preparation. Both patients and health systems may benefit from efforts to address these patient-centered themes of quality care through quality measures for TJA (eg, improving the psychological challenges of recovery). Future quality measures, such as assessment of patient experience, may be made more patient centered if they measure and improve aspects of care that matter to patients. [Orthopedics. 2021;44(2):117-122.].

Practical utility of mixed methods research in pharmacy practice

PURPOSE

Our aim was to review key methodological concepts and provide a practical guide to employing mixed methods research to enhance pharmacy practice research.

SUMMARY

Mixed methods research provides multiple organized analytic perspectives to thoroughly investigate complex social and scientific problems in a methodologically rigorous manner. This research design incorporates collection and analysis of both qualitative and quantitative data components to create a thorough understanding of a complex question. The 5 most commonly identified reasons for conducting mixed methods research include triangulation, complementarity, development, initiation, and expansion of results. For research questions that benefit from mixed methods research, we review how to structure the study, including timing, sequencing, and prioritization of methods. Illustrative examples from the literature highlight the utility of this methodology for clinical and operational pharmacy research questions.

CONCLUSION

Mixed methods designs can enhance pharmacy research inquiry, provide a means to understand complicated issues, and uncover optimal interventions.

Nurturing the digital baby: Open innovation for development and optimization

The primary aim around developing and optimizing an electronic health record is to improve patient care and population health. The objective of this study is to design and evaluate an action research approach for the optimization of the design of a summary page artefact within an electronic health record for newborn healthcare. An action research approach was chosen for its participatory democratic process for developing practical knowledge and solutions. Collaborative workshops lead by an independent graphic facilitator with a 'bottom up' approach, involving self-selected motivated members from multidisciplinary healthcare teams, were designed and conducted. To evaluate this approach, insights were drawn from behavioural and design science paradigms to demonstrate that knowledge and understanding of the design problem and its solution were acquired in building the optimized summary page artefact. Information system development for healthcare requires consideration not just of what we do but how and why we do things. Our analysis demonstrates that action design research represents an agile and lean approach for successful optimization and implementation of information system development in healthcare.

Defining Future Research Priorities in Donation and Organ and Stem Cell Transplantation With Patients, Families, Caregivers, Healthcare Providers and Researchers Within the Canadian National Transplant Research Program

Supplemental digital content is available in the text.

Background

Patients, families, and caregivers have a unique understanding of the diseases they live with and provide care for every day. Their experience and expertise are important and should be taken into consideration when determining research priorities. The aim of this study was to gather the perspectives of Canadian patients, families, caregivers, researchers, and healthcare professionals on what research priorities were important to them in the field of organ and hematopoietic cell transplantation (HCT) and donation within the Canadian National Transplant Research Program (CNTRP).

Methods

The CNTRP developed a national consultation process, which included a Web-based survey and in-person workshop, to ascertain and validate the viewpoints of the Canadian donation and transplant community. The Web-based survey identified 3 principal research priorities (increasing donation, developing better antirejection drugs and developing tolerance), which were further refined and prioritized during the one-and-a-half day national workshop held in Toronto in November 2015.

Results

A total of 505 participants answered the Web-based survey, and 46 participants (28 patients, 12 researchers and 6 healthcare professionals) participated in the in-person workshop. Workshop participants ranked the following 2 priorities as the most important in the fields of donation, HCT, and solid organ transplantation: methods for developing a culture of donation (within healthcare organizations and throughout society); and methods for improving graft survival and antirejection therapy.

Conclusion

The CNTRP will use these results to prioritize future research projects and studies in donation, HCT, and solid organ transplantation in the years to come.

Kidney Transplant Recipients' Perspectives on Cardiovascular Disease and Related Risk Factors After Transplantation: A Qualitative Study

Background

Cardiovascular disease (CVD) is a major cause of mortality among kidney transplant recipients (KTRs). These patients have a high prevalence of risk factors, such as hypertension, diabetes, and dyslipidemia. Despite regular medical care, few of them reach the recommended therapeutic targets. The objective of this study is to describe KTRs' perspectives on CVD and related risk factors, as well as their priorities for posttransplant care.

Methods

Twenty-six KTRs participated in a semistructured interview about their personal experience and offered their perspectives on CVD risk factors posttransplant. The interview was digitally recorded and the transcripts were analyzed using a thematic and content methodology.

Results

CVD and related risk factors appear to be underestimated and trivialized. Only 2 of 26 patients identified CVD prevention and treatment as a priority. The most important posttransplant priorities identified by patients were related to immunosuppressive drugs (13 of 26), posttransplant follow-up (10) and graft survival (9). However, 21 of 26 patients stated they wanted to be better informed about posttransplant CVD risk factors.

Conclusions

CVD and related risk factors are not a priority for KTRs, and the importance of CVD is underestimated and trivialized. KTRs did recommend that tailored information be provided by various professionals and at several points in the transplantation process. This knowledge will help us develop a new approach to increase awareness of posttransplant CVD and related risk factors.

Applications of mixed-methods methodology in clinical pharmacy research

Introduction Mixed-methods methodology, as the name suggests refers to mixing of elements of both qualitative and quantitative methodologies in a single study. In the past decade, mixed-methods methodology has gained popularity among healthcare researchers as it promises to bring together the strengths of both qualitative and quantitative approaches. Methodology A number of mixed-methods designs are available in the literature and the four most commonly used designs in healthcare research are: the convergent parallel design, the embedded design, the exploratory design, and the explanatory design. Each has its own unique advantages, challenges and procedures and selection of a particular design should be guided by the research question. Guidance on designing, conducting and reporting mixed-methods research is available in the literature, so it is advisable to adhere to this to ensure methodological rigour. When to use it is best suited when the research questions require: triangulating findings from different methodologies to explain a single phenomenon; clarifying the results of one method using another method; informing the design of one method based on the findings of another method, development of a scale/questionnaire and answering different research questions within a single study. Two case studies have been presented to illustrate possible applications of mixed-methods methodology. Limitations Possessing the necessary knowledge and skills to undertake qualitative and quantitative data collection, analysis, interpretation and integration remains the biggest challenge for researchers conducting mixed-methods studies. Sequential study designs are often time consuming, being in two (or more) phases whereas concurrent study designs may require more than one data collector to collect both qualitative and quantitative data at the same time.

Perspectives of Patients, Caregivers and Researchers on Research Priorities in Donation and Transplantation in Canada: A Pilot Workshop

BACKGROUND

It is vitally important to seek input from key stakeholders to increase the quality and relevance of health-related research and accelerate its adoption into practice. Patients and caregivers have rarely been involved in setting research priorities in the transplantation and donation field. The objectives of this explorative study are: (i) to discuss research priorities within the Canadian National Transplant Research Program during a priority-setting exercise with patients, caregivers, organ donors and researchers and (ii) to compare the identified priorities with research published in 2 prestigious transplantation journals.

METHODS

A pilot workshop attended by 10 patients and caregivers and 5 researchers was held in Montréal (Quebec, Canada) in August 2014 to identify research priorities. Priorities were identified using a thematic analysis of the workshop transcription conducted by multiple coders. These priorities were compared with the topics of research articles published in 2 major transplantation journals between 2012 and 2014.

RESULTS

The themes of the 10 research priorities identified by study participants were related to different research domains: social, cultural, and environmental health factors (4); biomedical or clinical (4); and research about health systems and services (2). 26.7% of the research articles published were related to the identified priorities. Thirteen percent looked at ways to improve graft survival and 8.5% looked at the development of tolerance, 2 priorities identified by participants. Fewer than 5% examined the other 8 research priorities identified as important by workshop participants.

CONCLUSIONS

This is the first study reporting patients' and researchers' priorities in the field of transplantation and donation in Canada. There is a discrepancy between topics that key stakeholders find important and research published in 2 major transplantation journals. The research priorities identified during our initial workshop will be validated through a national survey and workshop.

Qualitative research in clinical epidemiology

This chapter has been written to specifically address the usefulness of qualitative research for the practice of clinical epidemiology. The methods of grounded theory to facilitate understanding of human behavior and construction of monitoring scales for use in quantitative studies are discussed. In end-stage renal disease patients receiving long-term hemodialysis, a qualitative study used grounded theory to generate a multilayered classification system, which culminated in a substantive theory on living with end-stage renal disease and hemodialysis. The qualitative data base was re-visited for the purpose of scale development and led to the Patient Perception of Hemodialysis Scale (PPHS). The quantitative study confirmed that the PPHS was psychometrically valid and reliable and supported the major premises of the substantive theory.

Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review

Qualitative methods are progressively being implemented by researchers for exploration within healthcare. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature. This integrative review aimed to exam the contribution of qualitative research in burns care and subsequent rehabilitation. Studies were identified using an electronic search strategy using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary research in English between 2009 to April 2014 using Whittemore and Knafl's integrative review method as a guide for analysis. From the 298 papers identified, 26 research papers met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6-53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research.

How theory is used and articulated in qualitative research: development of a new typology

There is a long tradition within qualitative research of theory being central and of critical importance. Qualitative research theory often equates with the methodologies used but this is a complex relationship, plagued by lack of consensus among scholars regarding how theory and methodology are related. This article furthers the debates on how theories are used in qualitative research, how they might influence a study and how they are articulated in publications. The aim is to provide a framework through which the relationship between theory and qualitative research can be understood. We propose a five-point typology on the levels of theoretical visibility, testing this against a range of published research from five key international health, medicine and social science journals. The typology captures a range of visibility--from seemingly absent through to highly visible and applied throughout. There was a clear gradient in this assessment--only a minority appeared to use theory consistently throughout a study. We outline several challenges to consistently applying theory in qualitative research and suggest potential solutions. This article is based on the argument that lack of theory in qualitative research undermines its quality. The typology is offered to assist researchers in applying theory in their own research and critiquing its use in the work of others.

Patient barriers to and enablers of deprescribing: a systematic review

BACKGROUND

Inappropriate medication use is common in the elderly and the risks associated with their use are well known. The term deprescribing has been utilised to describe the complex process that is required for the safe and effective cessation of inappropriate medications. Given the primacy of the consumer in health care, their views must be central in the development of any deprescribing process.

OBJECTIVES

The aim of this study was to identify barriers and enablers that may influence a patient's decision to cease a medication.

DATA SOURCES

A systematic search of MEDLINE, International Pharmaceutical Abstracts, EMBASE, CINAHL, Informit and Scopus was conducted and augmented with a manual search. Numerous search terms relating to withdrawal of medications and consumers' beliefs were utilised.

STUDY ELIGIBILITY CRITERIA

Articles were included if the barriers or enablers were directly patient/carer reported and related to long-term medication(s) that they were currently taking or had recently ceased.

STUDY APPRAISAL AND SYNTHESIS METHODS

Determination of relevance and data extraction was performed independently by two reviewers. Content analysis with coding was utilised for synthesis of results.

RESULTS

Twenty-one articles met the criteria and were included in the review. Three themes, disagreement/agreement with 'appropriateness' of cessation, absence/presence of a 'process' for cessation, and negative/positive 'influences' to cease medication, were identified as both potential barriers and enablers, with 'fear' of cessation and 'dislike' of medications as a fourth barrier and enabler, respectively. The most common barrier/enabler identified was 'appropriateness' of cessation, with 15 studies identifying this as a barrier and 18 as an enabler.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

The decision to stop a medication by an individual is influenced by multiple competing barriers and enablers. Knowledge of these will aid in the development of a deprescribing process, particularly in approaching the topic of cessation with the patient and what process should be utilised. However, further research is required to determine if the proposed patient-centred deprescribing process will result in improved patient outcomes.

Mixed-methods research in pharmacy practice: basics and beyond (part 1)

This is the first of two papers which explore the use of mixed-methods research in pharmacy practice. In an era of evidence-based medicine and policy, high-quality research evidence is essential for the development of effective pharmacist-led services. Over the past decade, the use of mixed-methods research has become increasingly common in healthcare, although to date its use has been relatively limited in pharmacy practice research. In this article, the basic concepts of mixed-methods research including its definition, typologies and advantages in relation to pharmacy practice research are discussed. Mixed-methods research brings together qualitative and quantitative methodologies within a single study to answer or understand a research problem. There are a number of mixed-methods designs available, but the selection of an appropriate design must always be dictated by the research question. Importantly, mixed-methods research should not be seen as a 'tool' to collect qualitative and quantitative data, rather there should be some degree of 'integration' between the two data sets. If conducted appropriately, mixed-methods research has the potential to generate quality research evidence by combining strengths and overcoming the respective limitations of qualitative and quantitative methodologies.

Studying the social construction of cancer-related fatigue experience: the heuristic value of Ethnoscience

OBJECTIVES

Patients' lived experience of illness and health is receiving increased attention in the medical field. Understanding patients' perspective and experiences is an undoubted asset for efficient health interventions and improved clinical concordance. Patients' experiences of care and cure, however, are influenced by the cultural setting in which these experiences take place. This implies that health interventions should be "ecological" and attuned to the specific sociocultural context of the patients.

METHODS

Our research group is conducting a cross-cultural qualitative study aimed ad exploring how fatigue (a symptom very common in cancer) is perceived and manifested by patients in different countries (Canada, Thailand, England and Italy). In order to achieve this, the study was design according to the method of Ethnoscience, that appeared to us the best suited to explore the meanings that patients attribute to their state and the linguistic patterns they use to describe it. In this paper we will describe in details the process of Ethnoscience and will discuss the heuristic value of this research approach.

RESULTS

Ethnoscience was an effective research strategy for exploring how beliefs and values shape symptoms and the behavioural manifestations of cancer related fatigue.

CONCLUSIONS

This paper discusses the heuristic value of Ethnoscience and its applicability to the study of health relate topics, particularly those where issues of social construction are important.

PRACTICAL IMPLICATIONS

Ethnoscience is a promising and innovative research approach, able to cast light on the way people experience and make sense of their illness.

Using mixed methods research in medical education: basic guidelines for researchers

CONTEXT

Mixed methods research involves the collection, analysis and integration of both qualitative and quantitative data in a single study. The benefits of a mixed methods approach are particularly evident when studying new questions or complex initiatives and interactions, which is often the case in medical education research. Basic guidelines for when to use mixed methods research and how to design a mixed methods study in medical education research are not readily available.

METHODS

The purpose of this paper is to remedy that situation by providing an overview of mixed methods research, research design models relevant for medical education research, examples of each research design model in medical education research, and basic guidelines for medical education researchers interested in mixed methods research.

CONCLUSIONS

Mixed methods may prove superior in increasing the integrity and applicability of findings when studying new or complex initiatives and interactions in medical education research. They deserve an increased presence and recognition in medical education research.

Qualitative research in clinical epidemiology

This chapter has been written to specifically address the usefulness of qualitative research for the practice of clinical epidemiology. The methods of grounded theory to facilitate understanding of human behavior and construction of monitoring scales for use in quantitative studies are discussed. In end-stage renal disease patients receiving long-term hemodialysis, a qualitative study used grounded theory to generate a multilayered classification system, which culminated in a substantive theory on living with end-stage renal disease and hemodialysis. The qualitative database was revisited for the purpose of scale development and led to the Patient Perception of Hemodialysis Scale (PPHS). The quantitative study confirmed that the PPHS was psychometrically valid and reliable and supported the major premises of the substantive theory.

Evaluative criteria for qualitative research in health care: controversies and recommendations

PURPOSE

We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria.

METHODS

We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them.

RESULTS

Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors.

CONCLUSION

Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

Healthcare preferences among lesbians: a focus group analysis

OBJECTIVE

The healthcare needs of lesbians are not well understood. We sought to characterize lesbians' experiences with, and preferences for, women's healthcare.

METHODS

We conducted three age-stratified focus groups (18-29, 30-50, and >50 years) with a total of 22 participants using a semistructured interview guide to elicit lesbians' experiences and preferences. We analyzed transcripts of these audiotaped sessions using the constant comparative method of grounded theory. Community-dwelling women who self-identified as lesbian and responded to advertisements were selected on first-come basis.

RESULTS

Participants voiced experiences and preferences for healthcare that emerged into three themes: desired models of care, desired processes of care, and desired patient-provider relationship. Each theme was further developed into multiple subthemes. Within the subthemes we identified issues that were specific to lesbians and those that were general women's health issues. Participants preferred, but did not always receive, care that is comprehensive in scope, person centered, nondiscriminatory, and inclusive of them as lesbians.

CONCLUSIONS

Healthcare providers, institutions, and society should adopt an inviting, person-centered approach toward lesbians seeking healthcare, assure them access to healthcare information, and establish healthcare delivery systems that take all aspects of health into account.

Checklists to improve the quality of the orthopaedic literature

Several checklists have been developed in an effort to help journals and researchers improve the quality of reporting in research. The CONSORT statement and the CLEAR NPT evaluate randomized trials. The MOOSE and QUOROM checklists evaluate meta-analyses. The STROBE checklists assists readers in evaluating observational studies and the STARD checklist was developed for diagnostic test evaluation. The checklists presented here provide an invaluable source of guidance to authors, journal editors and readers who are seeking to prepare and evaluate reports. As evidence-based medicine continues to establish itself as the new paradigm by which medicine is practiced, the need for good reporting for all research designs must also become commonplace as opposed to the exception.

Values and beliefs about obesity and weight reduction among African American and Caucasian women

Designing culturally relevant weight-reduction programs requires understanding of ethnic variations and illness beliefs. Preliminary data on the values and beliefs about obesity and weight reduction were obtained from women of different ethnic/racial backgrounds. Purposive sampling was used to recruit African American (AA) and Caucasian (C) women with a body mass index (BMI)>or= 30 from the general internal medicine clinics of a large tertiary care facility. Four focus groups (2 with AA women and 2 with C women) consisting of a total of 20 subjects were conducted in a 2-month period. AA women cited culture specific barriers to weight loss more so than did C women. AA women and C women also differed on how health care professionals could help them with weight loss. These findings have implications for nursing's role in the design of culturally relevant weight-loss programs.

Dying Young, Dying Poor: A Sociological Examination of Existential Suffering Among Low-Socioeconomic Status Patients

Palliating the whole person requires that medicine attend more fully to the phenomenon of existential suffering. The role of social factors, in particular, is often overlooked in attempts to understand why end-of-life suffering does not always respond to physiologic, psychological, and spiritual interventions. Using qualitative data from in-depth interviews with 33 low socioeconomic status (SES) terminally ill patients with cancer, I examine how a sociological framework can provide insights on existential suffering at the end of life. Specifically, I discuss how dying "off time" in the life course, being exposed to the illness trajectories of others, and experiencing social isolation and social death contribute to existential suffering among the terminally ill.

Reframing the evaluation of qualitative health research: reflections on a review of appraisal guidelines in the health sciences

In this article, we explore the form of evaluation put forward by guidelines used in the health sciences for appraising qualitative research and we begin to articulate an alternative posture. Most guidelines are derivative of the modes of assessment developed by clinical epidemiologists as part of the promotion of evidence-based medicine (EBM). They are predominantly proceduralist in orientation, equating quality with the proper execution of research techniques. We argue that this form of judgment assumes a fixed relationship between research practice and knowledge generated, and tends to over-simplify and standardize the complex and non-formulaic nature of qualitative inquiry. A concern with methods as objects of judgment in and of themselves restricts the reader's field of vision to the research process and diverts attention away from the analytic content of the research. We propose an alternative 'substantive' perspective that focuses on the analysis put forward, and regards methods as resources for engaging with and understanding the substantive findings and topic of inquiry. An important challenge is to find a way to embody such a form of judgment in practical assessment tools.

A cautionary tale: the dysfunction of American health care

Attempts to reform the US health care system in the 1980s and 1990s were inspired by the system's inability to adequately provide access, ensure quality, and restrain costs. In the era of managed care, after the Clinton administration's failed legislative effort at reform, access, quality, and costs are still problems, and medical professionals are increasingly dissatisfied. To aid understanding of why the system is now so dysfunctional, I have drawn upon discussions with thoughtful physicians about their direct experience. They raised important concerns not usually considered by health care reformers. Their central concern was about the abandonment of medicine's core values. They felt that health care has become dominated by large, bureaucratic organizations which may not honor these core values. Patients and physicians are often caught in conflicts between competing interests and demands. Those who work in health care may be subject to perverse incentives that discourage ethical practice. Health care leaders may be ill-informed, incompetent, self-interested, or even dishonest. Examples of attacks on the scientific basis of medicine have become more frequent. These worrying trends are not confined to the US. Physicians elsewhere should be skeptical of approaches to health care reform derived from the American model. European doctors should ensure the new health care initiatives do not undermine their core values or the best interests of their patients.

Attitudes of primary care physicians toward cancer-prevention trials: a focus group analysis

PURPOSE

Recruitment of low-income and minority women to cancer-prevention trials requires a joint effort from specialists and primary care providers. We sought to assess primary care providers' attitudes toward participating in cancer-prevention trial recruitment.

PROCEDURES

We conducted a focus group with seven Boston-based primary care providers serving low-income and minority women. Providers discussed knowledge, attitudes, and beliefs regarding their role in recruitment to prevention trials.

FINDINGS

A qualitative analysis of the focus group transcript revealed nine categories. Three categories related specifically to the primary care physician: 1) the dual role physicians play as advocates for both patient and research; 2) threats to maintaining the primary care relationship; and 3) general philosophy toward prevention. An additional six categories could be subdivided as they apply to the primary care physician, the patient, and the community: 4) trust/commitment; 5) benefits of the research; 6) access to the research; 7) knowledge and recall of the research; 8) influences of media coverage about the research; and 9) cultural sensitivity.

CONCLUSIONS

Investigators conducting cancer-prevention trials must address the concerns of primary care physicians to optimize recruitment of subjects- especially low-income and minority women-into trials.

Personal growth in medical faculty: a qualitative study

BACKGROUND

A physician's effectiveness depends on good communication, and cognitive and technical skills used with wisdom, compassion, and integrity. Attaining the last attributes requires growth in awareness and management of one's feelings, attitudes, beliefs, and life experiences. Yet, little empiric research has been done on physicians' personal growth.

OBJECTIVE

To use qualitative methods to understand personal growth in a selected group of medical faculty.

DESIGN

Case study, using open-ended survey methods to elicit written descriptions of respondents' personal growth experiences.

SETTING

United States and Great Britain.

PARTICIPANTS

Facilitators, facilitators-in-training, and members of a personal growth interest group of the American Academy on Physician and Patient, chosen because of their interest, knowledge, and experience in the topic area and their accessibility.

MEASUREMENTS

Qualitative analysis of submitted stories included initially identifying and sorting themes, placing themes into categories, applying the categories to the database for verification, and verifying findings by independent reviewers.

RESULTS

Of 64 subjects, 32 returned questionnaires containing 42 stories. Respondents and nonrespondents were not significantly different in age, sex, or specialty. The analysis revealed 3 major processes that promoted personal growth: powerful experiences, helping relationships, and introspection. Usually personal growth stories began with a powerful experience or a helping relationship (or both), proceeded to introspection, and ended in a personal growth outcome. Personal growth outcomes included changes in values, goals, or direction; healthier behaviors; improved connectedness with others; improved sense of self; and increased productivity, energy, or creativity.

CONCLUSIONS

Powerful experiences, helping relationships, and introspection preceded important personal growth. These findings are consistent with theoretic and empiric adult learning literature and could have implications for medical education and practice. They need to be confirmed in other physician populations.

Qualitative research for the study of cancer and age

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

How will we know "good" qualitative research when we see it? Beginning the dialogue in health services research

OBJECTIVE

To lay the foundation for an explicit review and dialogue concerning the criteria that should be used to evaluate qualitative health services research. Clear criteria are critical for the discipline because they provide a benchmark against which research can be assessed.

DATA SOURCES

Existing literature in the social sciences and health services research, particularly in primary care and medicine.

PRINCIPAL FINDING

Traditional criteria for evaluating qualitative research are rooted in the philosophical perspective (positivism) most closely associated with quantitative research and methods. As a result, qualitative research and methods may not be used as frequently as they can be and research results generated from qualitative studies may not be disseminated as widely as possible. However, alternative criteria for evaluating qualitative research have been proposed that reflect a different philosophical perspective (post-positivism). Moreover, these criteria are tailored to the unique purposes for which qualitative research is used and the research designs traditionally employed. While criteria based on these two different philosophical perspectives have much in common, some important differences exist.

CONCLUSION

The field of health services research must engage in a collective, "qualitative" process to determine which criteria to adopt (positivist or post-positivist), or whether some combination of the two is most appropriate. Greater clarity about the criteria used to evaluate qualitative research will strengthen the discipline by fostering a more appropriate and improved use of qualitative methods, a greater willingness to fund and publish "good" qualitative research, and the development of more informed consumers of qualitative research results.