Qualitative studies revisited: its importance in Family Medicine

Martin CS Wong 黃至生

HK Pract 2011;33:89-91

More than a decade ago, Prof. TP Lam discussed about the similarities between conducting qualitative research and the practice of Family Medicine,¹ which perhaps explained one of the reasons why qualitative research is becoming more popular among researchers in our discipline. I believe it still holds true that qualitative research is an important research method in Family Medicine as it is a method that is better suited for the evaluation of consultation process, patient's attitude towards diseases and health services, and communication skills which are important research areas in Family Medicine. Looking back at the history of academic research, many leading journals began to publish qualitative studies in the 1970s ² and some newer journals that appeared in 1980-1990s published only qualitative research studies.³ Although this research method is deep-rooted in sociology, anthropology and philosophy, during the last two decades, we have witnessed a drastic increase in the number of qualitative research studies that were conducted beyond their traditional discipline boundary.

Unfortunately, qualitative research is still often regarded by some as merely descriptive studies, involving few participants with low methodological rigor.⁴ In addition, the critics also argue that a qualitative research design cannot generate findings on prevalence, prediction, clinical outcomes, cause-and-effect and so it is often downplayed.⁵ The rather subjective nature of data interpretation could imply inter-rater variability being a problem; and purposive sampling has also been subjected to questions for readers to arrive at a definitive conclusion, due to the lack of generalizability and the presence of selection biases. Some might suggest that qualitative studies have undergone mistaken attempts to be evaluated by the evidence-based hierarchy and therefore their status could not be formally established.⁶ Although this is true to a certain extent and one can rarely find qualitative studies published in high impact international journals, I believe a more balanced perspective is needed.

Qualitative studies stem from strong theoretical traditions which apply rigorous methods. When performed and evaluated in an appropriate manner, they represent invaluable tools to extract important clinical data. In this issue of the Journal, Kung et al ⁷ conducted a focus group interview with family doctors having different training status working in general outpatient clinics (GOPCs). They explored their views on training modalities, current strengths and weaknesses of GOPC as a venue of Family Medicine (FM) training, as well as achievements of FM competencies and the future training opportunities of FM trainees. The findings allow a variety of themes to emerge. Please take a look at the rich information derived from their verbatim quotes – could the research questions be better addressed by other study methodologies? I doubt whether similarly rich data could be captured if we use a quantitative approach like surveys. The research questions which followed Kung's contribution would be: "what are the additional components that the vocational Family Medicine training programme should offer? How could we better equip the GOPCs to suit the training needs of our trainee doctors? Could the perceived manpower and resource implications be addressed from the policy-makers' point of view? Could protected time be allocated for trainees whilst maintaining the quality of healthcare services in the GOPCs?" These questions could not have emerged without the original ground work.

In this same issue, Lee et al ⁸ conducted six focus group discussions among parents and ladies without histories of HPV infection. Their understanding of cervical cancer like risk factors, aetiology, preventive strategies and their motivators and barriers to receive HPV vaccination were elicited. Again, if one goes into each verbatim quote generated by the thematic analyses, a number of research hypotheses could be further generated from this one single study. For instance, is there any deficit in health education on HPV vaccination in our community? What are the best strategies to facilitate access and to remove barriers to HPV vaccination among the parents? Based on their findings of the need for more community-based health promotion programme for HPV vaccination, what types of educational initiatives would be the most effective? Only when this research article is published could we have a stronger justification to generate further research questions.

Previous studies published in Family Medicine journals like the HK Pract ^{9, 10} have also allowed a more in-depth understanding of issues related to clinical practice. As highlighted by Bradley et al (2006),¹¹ qualitative methodologies can generate rich information about healthcare including patient preferences, clinical decision-making, values and health beliefs which are culturally determined, patient satisfaction, health-seeking behaviors, and issues surrounding social disparities. They continued to assert the impact of qualitative research as a useful research design to provide critical insights to "inform development, translation, and dissemination of interventions to address health system shortcomings".¹¹

Because of the exploratory nature of qualitative studies, they provide more ideas for understanding the complexity of social phenomena using a collection of systematic and interpretative practices aiming to seek answers to enquiries that emphasize how social experience and actions are generated and sustained.^{12, 13} The large number of hypotheses generated could then be subsequently tested by quantitative designs, which are more confirmatory.

No matter what types of qualitative design like grounded theory, ethnography, case studies, narratology and discourse analysis, some key questions remain here: have we performed adequate number of qualitative research to address important issues on common clinical conditions? Do we know why some hypertensive patients do not prefer to take long-term medications in our local setting? Why would some elders prefer traditional Chinese medicine even if they know that Western doctors could easily relieve their symptoms? What are the in depth reasons why individuals at higher-risk of colorectal cancer are less likely than those average-risk subjects to undergo regular screening?

When we search our literature database, it is a pity that we do not have these research questions being answered in a proper manner by a well designed research methodology. These questions are indeed what we usually face in family practice, without such answers we might come across difficulties in communicating with patients and may lead to consultations which are less effective. In addition, policy-makers and researchers would be interested to have answers to these simple questions since they carry a substantial healthcare service implication, including healthcare costs. There is definitely a need to call for more training of qualitative methodology among physicians in our discipline; and most importantly, we should join our efforts to encourage these studies to be designed, planned, implemented and translated in our practice settings. Compared to other clinical disciplines, our specialty is particularly in need of local qualitative studies, without which we have much less research ideas to put into action.

One caveat though: there should be a balance between quantitative and qualitative studies and both should be interpreted alongside with one another to allow recommendations for best practice. The choice of research designs should also be dependent on the research questions posed. Mixed methodologies are now becoming more common-place and it is speculated that researchers should equip themselves with knowledge and techniques of both armamentaria in the future.