Qualitative methods used for effect studies and evaluations of healthcare strategies?

In effect studies and when healthcare strategies are evaluated traditional quantitative methods are usually used. Quantitative methods provide figures/measurements as results, which are relatively easy to understand and include in the discussions about prioritization and possible introduction of new healthcare activities. I will advocate for thinking in new ways and encourage politicians to consult more qualitative studies and as a consequence include results from qualitative studies in the ongoing assessment. Why is that? The reasons are manifold but some barriers also exist.

The well-known quantitative research studies in primary care can be and will often be initiated by healthcare planners. Questions like “What do we gain by implementing screening for breast cancer?” “What is the effect of educating GPs in advising on prevention of cardiovascular disease” are typical in this field. To obtain the answers randomized studies are designed and outcomes characterized by the phenomenon that they are measurable (e.g. survival, stroke, levels of cholesterol, number of prescriptions, etc.) are used. The weakness of using the traditional effect design is related to the fact that the research study takes place in the real world, where participation depends on the interest, economy, and feasibility of the study. Moreover, there is a logistical barrier, when the study as a rule does not originate from one centre but from many, as is often seen in general practice research. Another very important obstacle to carrying out effect studies is the risk of non-participation, when the randomization has to be done before acceptance of participation. Therefore it can be very hard to secure the power in the study and negative results will possibly be wrongly interpreted. Using qualitative methods can perhaps add another interpretation.

When the qualitative approach has been used in primary healthcare research, it has often been done by persons affiliated with the area, such as for example general practitioners, who have a great deal of experience in handling healthcare activities, a surgery, staff, and patients. They are interested in having answers to everyday questions like “Why does Mrs Jensen act as she does?” or “How can we improve our diabetes care?”, where the obvious method to use is the qualitative approach. As a result of increased focus on the need for development at all levels of the healthcare system, more resources are channelled into research and more qualitative studies are carried out and published. This has also been the trend in the Scandinavian Journal of Primary Health Care and during the last year subjects such as chronic fatigue syndrome [1], cardiovascular risk [2], depression [3], students’ consultations skills [4], motivation for visiting physicians [5], prescribing of antibiotics [6], urinary incontinence [7], and general health [8] have been touched upon in a qualitative setting. The way of gaining information from patients and providers has also widened, including for example focus-group interviews, single interviews, narratives, video recordings, and written life histories.

Traditionally, qualitative methods have been used by ethnographers, anthropologists, and sociologists to describe cultures, and they represent the inductive way of seeking out theories. As the qualitative method is used more and more in healthcare research and by researchers raised in the classical medical scientific methods (normally using deductive logic), it is being developed towards a “handy” and better known method in our field.

How do we combine the advantages of qualitative and quantitative methods?

It is seen more and more that the qualitative method is used in combination with quantitative methods. When used in combination the method has been called mixed methods, mixed model studies [9], methodological triangulation [10], or multimethod clinical research [11]. Whatever it has been called or will be called it is rational to be pragmatic and plan with a combination of methods in research projects [12]. Different models can be considered. For example, qualitative studies can be used for developing quantitative tools (interviews can lay the groundwork for questionnaires), qualitative methods can help in explaining quantitative results (e.g. interviews with GPs to explore the benefits of participating in continuing medical education), quantitative methods can enlarge on qualitative studies (results from questionnaires can verify results from interviews), or quantitative and qualitative methods can be used on an equal basis and produce parallel results. This last model is the one that is interesting to use in evaluating research, especially where logistical challenges or no obvious outcome measures are present.

How do we interpret and weight results from studies presenting qualitative and quantitative results in combinations?

This is a crucial question, especially if using mixed-method findings conflicts. A recently published article [13] discusses this in relation to a specific study that had been carried out. It points out the value of collecting both types of data within a single study and outlines an approach to deal with apparent discrepancies between qualitative and quantitative research data.

Publishing results derived from different methods

It is always a challenge to write a scientific manuscript. To combine results derived from two different methods in one manuscript seems even harder. That challenge is, however, well worth seizing as a researcher but also as an editor to get valuable results published in a sound way. Allow me to refer to a valuable guide for writers and reviewers of qualitative as well as quantitative manuscripts by Kirsti Malterud published in the Lancet in 2001 [14].

There is no doubt that the qualitative method can add evidence to evaluations of healthcare strategies and effect studies when designed appropriately in combination with quantitative methods.