June 2006 : No 9

Qualitative Research: Its Relevance and Use in Musculoskeletal Medicine

Bie Nio Ong

Primary Care Sciences Research Centre, Keele University, Keele

David A Coady

Rheumatology Department, Freeman Hospital, Newcastle upon Tyne

Reports on the Rheumatic Diseases Series 5 : Topical Reviews

  • Qualitative research aims to understand the way that people interpret and give meaning to their experiences
  • Qualitative research allows for exploration of language, identification of regularities, comprehension of the meaning of text, and/or action and reflection
  • Qualitative researchers use a wide range of methods, including observation, interviews, and study of documentary sources
  • Qualitative analysis aims to fully exploit the richness of the material
  • The study of musculoskeletal conditions lends itself very well to qualitative approaches, which provide insights into the way people live with pain and disability, how patients and clinicians interact, and how professional education can be improved

Introduction

Qualitative research aims to understand people's experiences and interpretations of life events, and as such these approaches are particularly useful in studying the way people live with and adapt to musculoskeletal conditions. This review starts with providing examples of how qualitative research has been used in examining musculoskeletal conditions from both the patients' and health professionals' perspectives, and how qualitative research often complements quantitative research. We place this body of work within the wider context of its application in health research before discussing the nature and forms of qualitative research more generally. This is followed by an explanation of the methods used and the type of analyses carried out. Further issues such as ethics, the quality of qualitative research and user involvement are also considered.

Relevance and application in researching arthritis

Qualitative studies from within the musculoskeletal literature have often addressed one of the following issues: understanding and assessing needs and outcomes, exploring the experience of living with a particular condition, or developing services. Single studies may contain one or more of these issues, and combine several methods and include a diverse set of participants ranging from patients, the general public and medical students through to doctors, nurses and therapists.

Rheumatoid arthritis (RA) has been an important topic area, and the early studies by Bury1 and Williams2 are still considered seminal landmarks in the literature as they provide a conceptual analysis of the impact of RA on people's interpretation of their life's experience and biography. Ryan3 has explored patients' experiences of living with RA in an attempt to understand the global impact of the disease. Ryan argues that this in-depth understanding from the patient's perspective is needed to allow nurses to adopt an holistic approach to patient care. Similarly the in-patient experience for new patients with RA (less than 3 years since diagnosis) has been explored.4 The consultation process between doctors and patients has been studied in detail, particularly with respect to the interpretation of reassurance among patients attending rheumatology clinics. Donovan and Blake5 performed a longitudinal study where consultations between doctors and patients were tape-recorded. Patients were interviewed following the consultation and their perception of the reassurance given was compared to what actually occurred during the consultation process. It was found that the clinician's traditionally held beliefs of reassurance (such as 'You've only got mild arthritis') often served to fan patient anxiety ('... If it is this bad now, what will it be like when it is severe?').

Qualitative methods have been used to assess needs and allow the development of services. Bath et al6 interviewed 15 patients with the aim of assessing the psychological needs of patients with RA in order to develop psychological interventions to be delivered by nurses. Issues for service development were identified by O'Hare et al7 while exploring the perceptions of both health care professionals and patients of the pharmaceutical care issues relating to RA.

Qualitative methods can play a key role in validation studies – for example, the validity of asking patients about early morning stiffness has been questioned through qualitative exploration.8 Focus groups with patients have been used to explore patient-based outcomes for RA. It was found that no existing measures captured outcomes considered important by patients.9 In a similar vein Marshall et al10 held a series of focus groups involving patients on anti-TNF therapy. These again identified patient-defined treatment benefits, such as social changes and 'well-being', that were not being captured elsewhere.

In the area of medical student education qualitative work involving students has been undertaken to identify musculoskeletal learning needs11 as well as in the assessment of educational resources,12 learning methods and learning styles.13 It has also been used in the design of musculoskeletal curricular content and changes, for both medical students14 and GPs.

With regard to osteoarthritis (OA) the work by Sanders et al15 is important because it highlights the fact that older people consider OA pain and disability as an inevitable part of the ageing process and/or their own biography. The consequence of this perception is that they underuse available health care resources, and thus do not access treatments that might alleviate their problems. Focusing specifically on the experiences of people with knee OA, Howse et al16 confirm those findings. Psychologists have studied the processes that mediate between bodily changes experienced by older people and whether and how these are translated into symptoms of illness. They argue that health attitudes such as body awareness, stress and depression or anxiety, coupled with perceived seriousness and recurrence of changes, may influence people's interpretations and shift their experience into the realm of illness.17

Back pain has been studied by many social scientists, and a range of issues has been discussed in the literature. One of the primary contested areas focuses on establishing pain as a clinical category. The history of the emergence of chronic low back pain as an accepted discourse attests to this struggle for recognition.18 Lillrank19 has demonstrated that within the therapeutic encounter tensions arise concerning the believability of back pain. The challenge of translating the internal experience of pain into recognisable symbols such as words and gestures that are acceptable to clinicians has been discussed by Ong and Hooper.20

Work has also been undertaken to gain patients' insight into chronic widespread musculoskeletal pain,21,22 illustrating similar issues concerning believability, uncertainty and identity. The importance of accessing a direct patient's account and comparing this with the perspective of the clinician treating the patient has been expressed in a paper written jointly by a patient, GP and researcher.23 Further work has been carried out on the attitudes of doctors towards chronic pain,24 the effectiveness of treatment programmes,25 and factors that influence a patient's own motivation to change.26

This review cannot provide a comprehensive survey of all the relevant examples of qualitative research as applied to musculoskeletal conditions, but this section should give the reader a useful starting point for further exploration of a fascinating body of research in this field.

The use of qualitative research in health care

While we focus in this review on the way in which qualitative research contributes to a better understanding of musculoskeletal conditions, reference needs to be made to the wider context of its use in the field of health and health care. The application of qualitative approaches is extremely wide, and can be broadly subdivided into the following:

  • Stand-alone research: mainly focusing on the experience of specific illnesses or conditions,27 or on the interactions between clinicians and patients28
  • Embedded in quantitative studies such as epidemiological surveys, in order to provide more in-depth insight into population-level findings29
  • Complementing trials to investigate patients' reasons for participation and understanding of allocation30 or to examine barriers to recruitment as related to lay understanding of trials31
  • As a device to develop survey questions or specific assessment tools such as the MYMOP ('Measure Yourself Medical Outcome Profile'), a patient-centred outcome measure.32

It is always useful to look beyond the boundaries of one's own field in order to assess whether insights from other fields may offer pointers and a broader understanding. Considering the list provided above, knowledge and tools are transferable to the musculoskeletal field such as the application of the MYMOP. This tool is currently being used to agree patient-defined outcomes in back pain clinics and to assess pain and discomfort pre and post intervention (e.g. in the Central Cheshire PCT physiotherapy service).

The nature and purpose of qualitative research

Having given examples of the use of qualitative research it is appropriate to discuss now in more depth what qualitative research actually is. We take as the point of departure that qualitative research has a long history in the social sciences, and has been increasingly adopted in health and health services research.33 Yet, at the same time, we do not intend to exaggerate the uniqueness of qualitative research, and endorse the argument made by Murphy and Dingwall34 that qualitative research can contribute to knowledge in ways that are different from and complementary to quantitative research (such as surveys, clinical trials etc). Furthermore, similarities in approach exist between qualitative research and encounters between patients and health professionals where the latter are trying to understand how people feel about illness by 'interviewing' their patients.

As to be expected no single definition of qualitative research exists, and some writers have described 'preferences' rather than provide a clear definition. For example, Hammersley35 offers a broad list, including a preference for the analysis of words and images, for observation and unstructured interviewing, and for focusing on the meanings and perspectives of the people being studied. Following Hammersley, Silverman36 proposes a pragmatic approach whereby the choice for qualitative research should be led by the type of problem to be researched, while recognising the need to implement rigorous and critical standards that improve the robustness of the findings. Moreover, he acknowledges the existence of a wide variety of theories and approaches within the qualitative tradition. Bryman37 emphasises the view that theory is developed 'bottom-up' from research findings. Given the fact that many views co-exist, for this review we select the approach taken by Murphy and Dingwall34 as it seems the most appropriate because their discussion of the contribution of qualitative research is directed towards its relevance for health services research.

Murphy and Dingwall describe the distinctive contribution of qualitative research as follows:

  • Description Many examples of detailed studies of health care organisations have uncovered the often invisible routines that shape the delivery of care and decision-making. One key strength of this type of research is that it allows a description of what actually happens, rather than what people say happens or what is supposed to happen.38 Murphy and Dingwall conclude that this can help to ensure that in quantitative research the right things are being counted. This is important because in health care one often is confined to counting what can be counted.
  • Process A systematic application of qualitative research can provide explanation of why and how things happen the way they do. For example, research on the uptake of innovations in primary care39 demonstrates the complex and dynamic processes of how resistance against and drive towards change interact. This work provides a better understanding into how clinical practices can develop within organisational contexts.
  • Flexibility and discovery Because qualitative research design is not fully specified at the start it allows for adaptation to changing circumstances in the field, and unanticipated discoveries can be made. For example, a Nordic study focused on people suffering from chronic pain.40 In the interviews they discovered that while people were providing detailed narratives, they simultaneously used their body and body gestures to express pain. This made the researchers aware of the complex interplay between speech and gestures, and thus they extended their research to include a study of non-verbal expressions of pain.
  • Context and holism Qualitative researchers explicitly acknowledge the complexity of life and human relationships. Thus, rather than isolating variables for investigation, they attempt to study them within context – most commonly within the 'real world'. A study comparing the care provided for people with chronic pain and illness in both North and South American environments demonstrated the importance of cultural context in communications between professionals and patients.41
  • Uncovering the informal organisation Because qualitative research attempts to 'get under the skin' it has the capacity to uncover the processes and undercurrents that the formal appearance of organisations hides. A classical study of the introduction of general management in the National Health Service in the 1980s42 demonstrates how 'old-style' administrative thinking continued underneath the 'new-style' business-inspired management model.

Given the above framework we argue that the selection of a qualitative approach depends on the purpose and circumstances of the research. The particular strengths of qualitative research allow for exploration of language, identification of regularities, comprehension of the meaning of text, and/or action and reflection.43

Key methods in qualitative research

A wide range of methods are used within qualitative research,44 and in this review we can only outline the main methods briefly.

Observation

Observational research relates to acquiring data in the field, mostly by watching and listening, and then interpreting the events that occur in the lives of the subjects under study. Observation can be carried out in an unstructured or structured way.45 Becker46 describes the unstructured approach as participant observation:

The participant observer gathers data by participating in the daily life of the group or organisation he studies. He watches the people he is studying to see what situations they ordinarily meet and how they behave in them. He enters into conversation with some or all of the participants in these situations and discovers their interpretations of the events he has observed.

Thus, the researcher is 'immersed' in the area under study, and analytical categories are developed during the course of the study. In a 'pure' application of this method participants do not know the researcher as a researcher. Nowadays, this type of covert research is generally not considered ethically acceptable. The structured approach may employ a design whereby pre-specified procedures for when and what to observe or sample are specified,47 and pre-determined analytical categories may be used.

Both approaches are open to criticism. First, full immersion into the area of study or 'going native' may mean that the researcher loses his or her awareness of being a researcher and is drawn into the participants' perspective.48 Second, the danger of ethnocentrism exists, 'that is of remaining so detached from the setting under observation that (s)he fails to penetrate the superficiality of his or her own initial observations of the setting'.45,49

Interviews

Qualitative interviews aim to directly access people's experiences and their interpretations.50 Thus, the act of listening is more important than the act of questioning and therefore interviews tend to be unstructured (free-flowing and participant-led) or semi-structured (thematic, offering participants the freedom to elaborate). A number of advantages are associated with these methods. First, they allow the collection of a broad range of views in response to open questions without pre-determining the result.51 Second, they provide the ability to explore certain issues 'in-depth' from the participants' perspective. Third, the flexibility of qualitative interviews is a means by which to uncover new areas or ideas that were not anticipated at the start of the research.

Interviews can be conducted with individuals or groups. Group interviews are commonly carried out in a focus group format, where a large amount of data is generated in a short space of time. This is achieved through directing the focus group with the aid of a topic guide that offers a framework for discussion, and the themes can be explored in more depth and breadth by exploiting group interaction.52

Qualitative interviews tend to be audiotaped (or videotaped) and fully transcribed for detailed analysis (see below). Focus groups tend to be recorded through extensive note-taking, often by more than one researcher. Videotaping is the most robust method as it allows for group interactions to be captured, including non-verbal behaviour.

Documents

A range of documents can be used in qualitative research, comprising existing material for secondary analysis or material that is explicitly produced for research purposes. Examples of the former include statistics, wherein the way in which it is decided what is deemed important data to record is of particular interest;34 organisational records such as minutes of meetings, policy documents and clinical notes; and biographical materials, including photographs and other visual forms. Material produced for research often takes the form of an invited diary with the purpose of capturing events close to when they occur and of recording routine and everyday life. Elliot53 has argued that diaries, as an important expression of auto/biography, have the potential to bring to the fore 'muted' accounts of health and illness. Diaries can also provide a way of gaining access to what actually happens in everyday life and to the subjective meanings attributed to such events, and it has been suggested that research into quality of life should focus on the study of day-to-day life and not just on retrospective in-depth interviewing.54

Action research

The research approaches discussed so far tend to be developed and driven by researchers, but the role of users (be they patients, carers, professionals or managers) in setting the research agenda and being involved in the research process is gaining more prominence.55 We will discuss the role of users in more detail below, but here we focus on the influence of this type of involvement on research methodology. The rise of user involvement, coupled with practitioner-led research,56 has raised the profile of action research. Meyer57 argues that it is more a style of research than a method, and it implies a 'political' commitment to ensuring that research has a use-value and contributes to change and improvement. In health care the potential of this approach has been recognised because it allows researchers to focus on user-defined outcomes, and a higher degree of involvement of practitioners in agenda-setting. Action research is based upon the principles of participation, democracy and social change and draws on a wide range of – often innovative – methods, including peer interviewing, visualisation, mapping and drama ('Participatory Learning and Action' – see 'Useful websites'). By focusing on the inclusive process of research and meaningful outcomes action research strives to combine understanding with change. When applied within the context of musculoskeletal research it can be educational, give voice to patients and carers, or be results-driven – e.g. improve clinical practice.

Analysis of qualitative research

Qualitative data reflect the experiences of people and the meanings they give to those experiences. This can be analysed by drawing themes and categories from the material, or by examining the narratives that are constructed.

Thematic analysis includes:

  • Defining concepts: understanding internal structures
  • Mapping the range, nature and dynamics of phenomena
  • Creating typologies: categorising different types of attitudes, behaviours, motivations
  • Finding associations: between experiences and attitudes, between attitudes and behaviours, between circumstances and motivations
  • Seeking explanations: explicit or implicit
  • Developing new ideas, theories or strategies.51

It is important to note that data collection and analysis are not strictly delineated activities within qualitative research, but analysis takes place continuously in order to inform purposeful data collection, refine questions and explore new avenues of inquiry.58 Often, researchers make use of data management systems such as NVivo37 that help to order the – often large – data sets, and facilitate analysis through structured search strategies.

One of the difficulties with thematic analysis is that context can be lost, and that the holistic nature of experiences is not captured. Narrative approaches offer an alternative in that they intend to maintain sensitivity to the storyteller's perspective, namely to the way they perceive and present their life, as shaped by history and socio-economic and cultural circumstances. Studies of health and illness have used this approach regularly, capturing the stories people tell of how they make sense of pain and disability.59 In order to reflect the 'real life' experiences narrative accounts tend to include verbatim quotations that are used as some indication of shared experience.27

Key issues in qualitative research

User involvement

In the last decade user involvement in research and development has become increasingly accepted. Users include not only users of health services, their carers and their social networks, but also health care professionals and managers who make use of research. Reasons to involve users include: accessing a range of different perspectives; identification and prioritisation of topics; assessment of the relevance of research; developing user and carer defined outcomes; accessing marginalised groups; and increasing enablement and empowerment of users. Users can be involved in all or some of the steps in the research process, and a useful handbook has been developed for that purpose.55

Ethics of qualitative research

In clinical research ethical issues are considered of key importance, and while risks in qualitative research are of a different magnitude, participants may be harmed psychologically or in professional or legal terms.2 To this end, qualitative researchers have adopted similar consent procedures, paying particular attention to informed and willing consent; peer review and ethics committee approval; careful and transparent analysis; and ensuring privacy and confidentiality. Thinking about the ethics of qualitative research involves measuring up benefits and risks, but these may be harder to predict than in clinical research. However, whatever research approach is being used all researchers need to be attuned to the possible anxiety, distress or reticence of research participants and to respond sensitively to these.60

Quality of qualitative research

With the advent of systematic reviews of the Cochrane type debates about assessing the quality of qualitative research have surfaced. There is considerable disagreement as to how this is best done, and translating quantitative review approaches for qualitative research or developing secondary summary and synthesis appear inappropriate. A number of frameworks have been proposed that accord due justice to the specific nature of qualitative research, emphasising different key characteristics – for example, the need to be reflexive (i.e. to share preconceptions), consider transferability of findings, and clearly describe interpretation and analysis;61 or use as primary markers the interpretation of subjective meaning, the description of social context, and attention paid to lay knowledge.62 Seale63 argues that researchers should have respect for the sheer variety of theoretical and methodological positions possible within social research. He emphasises that researchers learn a 'craft skill' that leads to the development of one's 'own style' which is based on a series of principled decisions that then need to be explicit when reporting research findings. Thus, there is no single way for assessing quality, but many qualitative researchers have accepted the need to adopt at least some broad guidelines that make decisions about design, methods, analysis, presentation and ethics explicit.64

Conclusion

Qualitative research used within musculoskeletal studies aims to provide insights into the way people live with and interpret their musculoskeletal pain and disability; how the interactions between patients and health care professionals can be understood; and more generally, how care processes and people's circumstances influence the way they cope with illness. The power of qualitative approaches lies in their ability to go beneath the surface and to examine fluctuation and change (particularly relevant in the case of musculoskeletal diseases), processes and complexity. As such, the contribution of qualitative approaches alongside clinical and epidemiological methods is considerable, whether separate or in mixed methods studies.

Useful websites

INVOLVE (promotes public involvement in NHS, public health and social care research)
www.invo.org.uk

Qualitative Health Research (journal)
www.ualberta.ca/~qhr

Campbell Collaboration (systematic reviews)
www.campbellcollaboration.org

NVivo (data management)
www.qsrinternational.com

Participatory Learning and Action (journal)
www.iied.org/NR/agbioliv/pla_notes/about.html

MYMOP (patient-defined outcomes)
www.hsrc.ac.uk/mymop/main.htm

National Centre for Social Research (seminars, workshops, qualitative training courses; interview and focus group techniques)
www.natcen.ac.uk

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