Family Practice Oxford University Press 1996

Vol. 13, Suppl. 1 Printed in Great Britain

Qualitative research: the research questions it can help answer, the methods it uses, the assumptions behind the research questions and what influences the direction of research. A summary of the panel discussion at the conference 'Exploring qualitative research in general practice'
Frances Griffiths
This paper describes the themes identified by the editor from the recording and transcripts of the panel discussion at the conference Exploring qualitative research in general practice. The editing process was a form of qualitative analysis in itself. The panel discussion was based on research questions developed by groups of conference participants during the conference lunch break. The research questions were selected for discussion by the panel chairman and panel members. The panel consisted of the conference speakers (DA, SH, MJ, CH, RJ) and chairman (MM) with other conference participants contributing comments (one contributor could not be identified from the recording). In this paper the discussion points made are attributed to the person speaking by initials following their comment. The text does not represent exact quotations but the editor has endeavoured to preserve the essence and meaning of the comments (FG). One criterion used in the selection of topics for discussion was whether the group of participants had produced a question. The panel decided to respond only to questions. We are programmed to look at research as questions but is research only about questions? (SH). proached with a qualitative method (DA), but 'what' questions such as "What are evidence-based guidelines?" may also use qualitative methods (SH). People may say that evidence-based guidelines are a good thing but act differently. To start making sense of that we need to ask doctors ' 'What do you mean by evidence?" The behaviour of GPs may be based more on the evidence of their own experience which is a different notion of evidence from that used in guidelines (CH). A research question such as "What precipitates people to present to their GP saying they are tired all the time?" raises other questions: "What does tiredness mean?" "Are people more tired now than they were?" "Has the meaning of tiredness changed?" (SH). The research question "What does drug-seeking behaviour really mean?" is a different order of question as it is trying to find out what drug-seeking behaviour means in a particular culture or society, rather like asking "What does going to church mean?" It is a sociological or anthropological question which cannot be answered by simply interviewing people. Developing an answer would involve starting from a particular theoretical perspective (e.g. Marxism or psychoanalysis) which may provide some insights, then finding a way of testing these out (DA). It is possible ask individuals "What does this mean to you?" The answers may be expressions of the bigger scheme or the individuals may give interesting idiosyncratic answers of their own. These answers only make sense against a background of the themes in society at the time, and those you have to discover by looking at the media, analysing newspapers, etc. (CH). To begin to answer the question "Do patients and GPs both want the same thing out of general practice?", the.different meanings and assumptions of two groups in society, doctors and patients, would have to be investigated . The question indicates the clash of two cultures but we do not know enough about them, it would be complex to investigate and the question as phrased is probably too big to get started (CH).
S27

Research questions that qualitative methods can help answer

Qualitative methods may provide useful tools for understanding phenomenon for which, at present, we have no really good working models, for example, why people do not take prescribed drugs as intended by the doctor (MM). 'Why' questions such as "Why do GPs not implement evidence-based guidelines?" are best ap-

Norton Medical Centre, Harland House, Norton, Stockton-on-Tees TS20 IAN, UK.

Family Practicean international journal

Methods used in qualitative research

A research question can be looked at from different angles and using different methods to provide different types of answer. This notion of triangulation can result in stronger and better research tools (MM). The different methods may be qualitative, quantitative or a mixture. A population survey may reveal the frequency of a symptom such as tiredness and how many people consult their doctor about it. To understand why some people go to see their doctor and others do not, some of those that attend the doctor and some that do not could be interviewed (RJ). An interview study can take many forms. One of the commonest used is the semi-structured interview where the interviewer has a schedule of areas to cover. Interviews of doctors about evidence-based guidelines may include "Have you heard of evidence-based guidelines?" "Do you know what in your clinical practice is based on evidence?" "Do you apply guidelines, when and where?" (DA). However, if the interview subjects are GPs, can a GP be the interviewer? One view is that you cannot study your own tribe because there is too much hidden culture and assumptions. The researcher needs to ask innocent questions to uncover this. However, there can be good and bad interviewers from all disciplines, it is partly a question of technique. A GP interviewing GPs will give a different interview and get a different story from a social scientist interviewer, but who is to say that one story is going to be more interesting or rewarding than the other? (CH). There are specific techniques that can be used within interviews to enhance the research data. For example, a research question about being tired all the time is using, what is know as standardized language of distress. All of life's problems from unemployment to marital problems come in the phrase 'tired all the time'. To work outwards from this label you could use free-association, asking question such as ' 'What do you mean by tired?'' ''What do you mean by all the time?" ''What do people who are not tired look like?" When looking at any condition it can be very revealing to ask about the exact opposite. If you ask someone taking diazepam "What effect does diazepam have on you when you take it?" the reply may be "Oh it does not have any effect". Asking "What would happen if you did not have diazepam?" would give a different series of answers. A different technique could be used for a research question, such as "What are the images which GPs have of themselves and their roles?" If you ask a doctor ''How do you see your role?" they are likely to freeze up as the question is so open-ended. One way around this would be using projective techniques. You could give them a series of scenarios, each one a description of what a GP does, and ask them which they most identify with, or give them a story of a GP and ask them to tell you about the doctor written about in the story. S28

This way the person interviewed can be more relaxed as they are not talking about themselves but projecting onto the story (CH). Interviews have to aim at finding out about things that are accessible to the person interviewed. If you asked a GP "What do you want from general 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 down as you can only find out what people can make sense of themselves (DA). A group interview could be used to develop, for example, a list of priorities for quality standards in general practice. The results from a group of GPs and a group of patients could be compared to see how much they match (RJ). A Balint group is a special form of group research which could look at when and why doctors follow evidence-based guidelines or not, and tease out some of the detail of this. Being from a different discipline, the psychoanalyst in the Balint group has the important role of heightening perception and observation to help the group see what is at that moment beyond the field of vision (SH). Observational studies can reveal the reality behind the rhetoric. For example a research question about the primary health care team may see the team as a group of professionals co-operating with each other. However, the members of the team come from a number of different professional subcultures. It would be interesting to do a flynon-the-wall observation to see how things actually worked (CH). Written material has been mentioned as a source of data about the prevailing culture. In trying to answer a research question such as 'What does tiredness mean?' in a literate society, looking at printed material such as newspapers and women's magazines is important in revealing the wider cultural themes. Doing this reveals a whole series of so-called depletion diseases based on mechanical metaphor such as 'running on empty' 'at a low ebb' 'drained' (CH). The historical study of a question about a symptom such as tiredness may use a series of medical texts, of which there are many from the eighteenth century onwards. A historian might look at the way words are used in certain contexts such as fatigue, as used by a psychiatrist or a pathologist. Newspapers and personal diaries or correspondence, if available, can also be used. However, historians are wary of seeing continuity in the use of, for example, diagnoses over time. To use the example of learning difficulties, historians would argue that it is difficult to be sure whether a diagnosis based on a number of symptoms made in the nineteenth century, such as feeble-mindedness, is the same as what we are talking about now in terms of learning difficulties (MJ). Health diaries have been used in the past to research illness behaviour but were dropped because of methodological difficulties. Patients would not complete them as they claimed they made them feel ill (DA).

Qualitative research; a discussion

Recently they have been used successfully in conjunction with interviews for looking at help-seeking behaviour. The diaries acted as an aide-memoir in the interviews, a blank entry sometimes reminding the person interviewed of what happened that day, such as a child falling out of a tree (?). A variation on this method is to ask people, for example, those that say they are 'tired all the time', to write a story about how they came to be tired all the time (CH). This method has also been used therapeutically (PC). In the eighteenth century a doctor attending a rich patient would ask the patient to transcribe their own experience and symptoms. The diagnosis was then negotiated between them, partly as the patient and doctor were considered equals. This was before what Foucault refers to as the development of a clinical gaze and the patient becoming an object that can be studied (MJ).

improving and mortality rates declining, there were certain sections of the population in certain parts of the country who were not benefiting from declining mortality rates. By asking 'Why did mortality rates decline?' you are avoiding a whole set of issues about health, medicine and disease in society (MJ).

Influences on the direction of our research

A researcher's experience and background will influence the way a research project develops; however, a much greater constraint on what research questions are tackled and how, is the availability of funding. Research has to be related to policy and has to be in the area of interest of the grant-giving bodies. This constraint is greater now that the big sums of research money are centrally controlled (RJ). Grant-giving bodies help create the culture that shapes the whole research enterprise and, in a sense, it has been ever thus. Major paradigms capture the research market for long periods of time (MM). The challenge is to get involved with the policy development of these grant-giving bodies (RJ). A problem for researchers, particularly in health service research, is that the questions we ask change before we answer them. There is a move towards research for quick decision-making where, rather than seeking a global answer to a research question, we do a short, focused, non-generalizable project, often with a mixture of research methods, to answer a specific health service problem. This process may emerge in the future as an important research paradigm and with this form of research the issues about generalizability would cease to matter (RJ). The research question about the use of evidence-based guidelines leads to a historical question about why evidence-based medicine has become so prominent now (RB). The basic medical sciences that emerged from the late nineteenth century have made a dramatic difference to diagnosis and treatment of certain medical conditions, and this is part of their legitimating power. This medical science is perceived by doctors and patients and, until the last 10-20 years, was perceived by the media as a major contribution to society. However, some of this optimism is beginning to dissolve, and part of this process is the challenge made by the legal profession, through law suits, and by the media, to the cultural supremacy of medical science. One of the reasons why experimentalism, bio-genetics, bioreduction is so potent now is because it is a reaction to some of that criticism and to those external forces trying to undermine the practice of medicine. Historians would see this process as a series of negotiations with the professional groups and different interests constantly shifting position (MJ). S29

The assumptions behind the research questions

A research question such as 'Are there limits to skill substation in primary care?' is about nurses taking on new roles, GPs delegating certain tasks and perhaps taking on other ones. However, there seems to be an agenda here about how different health care workers feel about changing roles and tasks. The question may have started as a statement 'There are limits . . .' (MM). What does 'limits' mean? Does it mean 'Are there limits to potential?' or does it mean 'Who is setting up barriers?' The question makes an assumption that there are limits (SH). Behind the question 'What does drugseeking behaviour really mean?' there seems to be an agenda about whether we approve of drug taking or not. There is a lot of feeling behind the questions we ask, they are not innocent they are knowing and are not so much questions as statements of a point of view. All facts, all data are values. For example, a researcher may have some feelings about evidence-based medicine that may affect the way in which the researcher sets about the research. Are we able to distinguish the value system in which we approach these questions and the type of research we do? (MM) A historian, if asked a question such as 'Why did mortality rates change in the twentieth century' would want to ask further questions, such as, 'Did they change?' 'Where does the evidence come from?' 'Who compiled the statistics?' and 'How and what do they tell us about groups within the population as well as the whole?' During the 1930s, for example, the rhetoric from public health officials and the government was that mortality rates were declining and standards of living were improving, but fairly close historical study of the figures they quoted suggests that, although in the population as a whole standards of health may have been

Family Practicean international journal

Our training as doctors has led us to trust experimental results or results of research based on large population samples and to lose our trust of our own perceptions and experiences. The word 'anecdotal' has become a sort of swear word, yet what is wrong with anecdotes? Some of the greatest breakthroughs in history have been made from anecdotes. As GPs and general practice researchers we have to develop trust in our own perceptions and the perceptions of others (CH).

Conclusion
Qualitative research is not an ultimate pathway to truth, but it is useful and can reach parts that other forms of research cannot (CH). At present, qualitative methods may be viewed as at the bottom of a hierarchy of methods with randomized controlled trials at the top.

Yet in the last 50 years one of the most major changes in health service provision in this country was the closure of psychiatric hospitals, and one of the key determinants of that was a qualitative study (DA).1 Whenever you look at the history of research you find that researchers have suddenly broken through a barrier and shown us something which we really did not see before. The question for medicine, and in particular for everyday general practice, is what is staring us in the face now that we just cannot see. Answering that question seems to be the exciting possibility for the kind of research approaches that have been discussed in this conference (MM).

Reference
1

Goffinan E. Asylums. Essays on the social situation of mental patients and other inmates. Hannondsworth: Penguin, 1968.

S30