3.2 Introduction to qualitative evidence and evidence-based healthcare

Introduction

This section provides an introductory perspective on qualitative synthesis, the relationship between evidence, qualitative evidence and health care practice and sets out a framework for considering the philosophic traditions associated with forms of research. A brief outline of some of the debates regarding qualitative synthesis is presented, although not with the intent of comprehensively addressing the significant variety of positions, but rather to assist in situating meta aggregation (the JBI approach to qualitative synthesis) as a methodology and where it sits within the wider debates.Importantly, key operational assumptions have been included in this section, as have the definitions of core terms for the process of extracting and synthesizing qualitative data. These definitions inform meta aggregation and represent a distinctive difference from other methods of qualitative synthesis that rely on the reviewer to re-interpret literature. The term meta aggregation is the formal name of the methodology, however, aggregative review, aggregative synthesis or meta synthesis are used interchangeably in this manual.

What is qualitative research?

Qualitative evidence or qualitative data allows researchers to analyze human experience and cultural and social phenomena (Jordan 2006). Qualitative evidence has its origins in research methods from the humanities and social sciences and seeks to analyze the complexity of human phenomena in naturalistic settings and from a holistic perspective (Ailinger 2003). The term ‘qualitative’ refers to various research methodologies including ethnography, phenomenology, qualitative inquiry, action research, discourse analysis and grounded theory. Research methods include interviews, whether group or individual and observation (either direct or indirect). Researchers who use qualitative methodologies seek a deeper understanding, aiming to “study things in their natural setting, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them” (Denzin 2005).

In the healthcare or medical context, qualitative research:

“...seeks to understand and interpret personal experiences, behaviors, interactions, and social contexts to explain the phenomena of interest, such as the attitudes, beliefs, and perspectives of patients and clinicians; the interpersonal nature of caregiver and patient relationships; the illness experience; or the impact of human suffering”. (Wong and Haynes 2004).

Qualitative evidence has a particular role in exploring and explaining why interventions are or are not effective from a person centered perspective, and address questions related to the usability, meaningfulness, feasibility and appropriateness of interventions. Similarly, qualitative evidence is able to explain and explore why an intervention is not adopted in spite of evidence of its effectiveness (Black 1994).  The strength of qualitative research lies in its credibility (i.e. close proximity to the truth), using selected data collection strategies that “touch the core of what is going on rather than just skimming the surface” (Greenhalgh 1997).

Qualitative Evidence and Healthcare

Qualitative methods and data are increasing in usage in evidence-based healthcare research. Instead of quantifying or statistically portraying the data or findings, qualitative research focuses on individuals and gives voice to the patient/client or provider in the healthcare decision-making process. As an example, the question: ‘What proportion of smokers have tried to give up?’ leads to statistical answers while the question ‘Why do people continue to smoke?’, leads the researcher into exploring the ideas and concerns people who smoke tobacco may have about their smoking habits (Greenhalgh 1997).

Qualitative research is undertaken because it:

“...has an important role in evidence-based health care, in that it represents the human dimensions and experiences of the consumers of health care. This type of research does not answer questions concerning the effectiveness of health care; rather it provides important information about such things as the appropriateness of care and the impact of illness. It also provides a means of giving consumers a voice in the decision-making process through the documentation of their experiences, preferences, and priorities...” (Evans 2002).

Qualitative research plays a significant role in understanding how individuals and communities perceive health, manage their own health and make decisions related to health service usage. It can assist to understand the culture of communities, in relation to implementing changes and overcoming barriers. It can also inform planners and policy makers about the manner in which service users experience health as well as illness, and can be used to evaluate activities of health services such as health promotion and community development.

Acknowledgement of the contribution that qualitative research findings make in improving the quality and relevance of healthcare conditions is increasing. As an example, Systematic reviews. CRD's guidance for undertaking reviews in health care published by the Centre for Reviews and Dissemination at the University of York states that ‘There is growing recognition of the contribution that qualitative research can make to reviews of effectiveness’ as it helps to develop an understanding of the people, the practices and the policies behind the mechanisms and interventions (CRD 2009).

Qualitative evidence comprises data that is expressed in terms of the meaning or experiences of acts or events rather than in terms of a quantitative measurement. (Barbour 1999, Moffatt et al. 2006, Forman et al. 2008) Arguably one of the best features of its contribution to research inquiry lies in its stories and accounts of living and its richness of meanings within its words (Forman et al. 2008).

Philosophical perspectives, research methodologies and methods

A philosophical perspective encompasses our assumptions of the theory and the research methodologies that guide research. There are three prevailing philosophical or guiding paradigms in current western health care research. The first is the positivist – or empirico- analytical –paradigm, often associated with quantitative evidence (see Chapter 3) while the other two, the interpretive and critical paradigms, are largely associated with qualitative evidence. In the interpretive paradigm, theory is inductive and concerned with exposing implicit meaning; it aims at understanding. The critical paradigm, like the interpretive, is inductive, however it aims to emancipate knowledge and practice. Each paradigm is encompasses a diversity of research methodologies and methods (methods being the specific approach to data collection).

An outline of the key research methodologies and methods associated with the interpretive and critical paradigms is shown in Table 2.1.

Table 2.1: A summary of qualitative philosophy, methodologies and methods.