And there are other lives, but they are in you. It was already said by Paul Éluard, that last century’s surrealist who had the bad idea of visiting Cadaqués accompanied by his wife, Elena Ivanovna Diakonova, better known as Gala. He was not very clever there, but his phrase did give for many more things.
For example, it has been used by many writers who love the unknown, myths and mystery. I personally knew the phrase when I was a young teenager because it was written as a preface to a series of science fiction books. Even, in more recent times, it is related to that other incorporeal world that is cyberspace, where we spend a more and more greater part of our life.
But, to help Éluard rest peacefully in his tomb at Père- Lachaise, I’ll tell you that I like more his original idea about our two worlds, between which we can share our limited life time: the real world, where we make the most part of the things, and the world of the imagination, our intimate space, where we dream our most impossible realities.
You will think that today I am very metaphysical, but this is the thought that has come to my mind when I started thinking about the topic that we are going to deal with in this post. And the fact is that in the realm of medicine there are two worlds too.
We are very used to numbers and the objective results of our quantitative research. As an example, we have our revered systematic reviews, which gather the scientific evidence available on a specific health technology to assess its efficacy, safety, economic impact, etc. If we want to know if watching a lot of TV is a risk factor for suffering this terrible disease that is fildulastrosis, the best thing will be to do a systematic review of clinical trials (assuming there are any). Thus, we can calculate a multitude of parameters that, with a number, will give us a full idea of the impact of such an unhealthy habit.
But if what we want to know is how fildulastrosis affects the person who suffers it, how much unhappiness it produces, how it alters family and social life, things get a little complicated with this type of research methodology. And this is important because the social and cultural aspects related to the real context of people are increasingly valued. Luckily, there are other worlds and they are in this one. I am referring to the world of qualitative research. Today we are going to take a look (a short one) at this world.
Qualitative research is a method that studies reality in its natural context, as it occurs, in order to interpret the phenomena according to the meanings they have for the people involved. And for this it uses all kinds of sources and materials that help us to describe the routine and the meaning of problematic situations for people’s lives: interviews, life stories, images, sounds … Although all this has nothing to do with the gridded world of quantitative research, both methods are not incompatible and may even be complementary. Simply, qualitative methods provide alternative information, different and complementary to that of quantitative methods, which is useful for evaluating the perspectives of the people involved in the problem we are studying. Quantitative research is a way to address the problem deductively, while qualitative uses an inductive approach.
Logically, the methods used by qualitative research are different from quantitative’s ones. In addition, they are numerous, so we will not describe them in depth. We will say that the specific methods most used are meta-synthesis, phenomenology, meta-ethnography, meta-study, meta-interpretation, the grounded theory, the biographical method and the aggregative review, among others.
The most frequently used of these methods is meta-synthesis, which starts with a research question and a bibliographic search, in a similar way to what we know about systematic reviews. However, there are a couple of important differences. In quantitative research, the research question must be clearly defined, while in qualitative research this question is, by definition, flexible and is usually modified and refined as data collection progresses. The other aspect has to do with the literature search, because in qualitative research it is not so clearly defined what databases have to be used and there are not the filters and methodologies available to documentarists to make revisions of quantitative research.
Also, techniques used for collecting data are different to those we are more accustomed to in quantitative research. One of them is observation, which allows the researcher to obtain information about the phenomenon as it occurs. The paradigm of observation in qualitative research is participant observation, in which the observer interacts socially with the subjects of the medium in which the phenomenon of study occurs. For example, if we want to assess the experiences of travelers on a commercial flight, nothing better than buying a ticket and posing as another traveler, collecting all the information about comfort, punctuality, attention provided by the flight staff, quality of the snacks, etc.
Another technique widely used is the interview, in which a person asks another people or group of people for information on a specific topic. When it is done to groups it is called, as it could not be otherwise, group interview. In this case the script is quite closed and the role of the interviewer is quite prominent, unlike in focus groups discussion, in which everything can be more open, at the discretion of the group’s facilitator. Anyway, when we want to know the opinion of many people, we can resort to the questionnaire technique, which polls the opinion of large groups so that each component of the group spends a minimum time to complete it, unlike the focus groups, in the that all remain throughout the interview time.
The structure of a qualitative research study usually includes five fundamental steps, which can be influenced according to the methods and techniques used:
- Definition of the problem. As we have already mentioned when discussing the research question, the definition of the problem has a certain degree of provisionality and can change throughout the study, since one of the objectives may be to find out precisely if the definition of the problem is well done.
- Study design. It must also be flexible. The problem with this phase is that there are times when the proposed design is not what we see in the published article. There is still a certain lack of definition of many methodological aspects, especially when compared with the methodology of quantitative research.
- Data collection. The techniques we have discussed are used: interview, observation, reading of texts, etc.
- Analysis of the data. This aspect also differs from the quantitative analysis. Here it will be interesting to unravel the meaning structures of the collected data to determine their scope and social implications. Although methods are being devised to express in numerical form, the usual thing is that we do not see many figures here and, of course, nothing to do with quantitative methods.
- Report and validation of the information. The objective is to generate conceptual interpretations of the facts to get a sense of the meaning they have for the people involved. Again, and unlike with quantitative research, the goal is not to project the results of possible interventions on the environment, but to interpret facts that are at hand.
At this point, what can we say about the critical appraisal of qualitative research? Well, to give you an idea, I will tell you that there is a great variety in opinions on this subject, from those who think that it makes no sense to evaluate the quality of a qualitative study to those who try to design evaluation instruments that provide numerical results similar to those of quantitative studies. So, my friends, there is no uniform consensus on whether you should evaluate, in the first place, or on how, in the second. In addition, some people think that even studies that can be considered of low quality should be taken into account because, after all, who is able to define with certainty what a good qualitative research study is?
In general, when we make a critical appraisal of a qualitative research study, we will have to assess a series of aspects such as its integrity, complexity, creativity, validity of the data, quality of the descriptive narrative, the interpretation of the results and the scope of its conclusions. We are going to continue here our habit of resorting to the CASPe’s critical appraisal program, which provides us with a template with 10 questions to perform the critical appraisal of a qualitative study. These questions are structured in three pillars: rigor, credibility and relevance.
The questions of rigor refer to the suitability of the methods used to answer the clinical question. As usual, the first questions are about elimination. If the answer is not affirmative, we will have resolved the controversy since, at least with this study, it will not be worthwhile to continue with our assessment. Were the objectives of the research clearly defined? It is necessary to value that the question is well specified, as well as the objective of the investigation and the justification of its necessity. Is the qualitative methodology congruent? We will have to decide if the methods used by the authors are adequate to obtain the data that will allow them to reach the objective of the investigation. Finally, is the research method used suitable for achieving the objectives? Researchers must explicitly say the method they have used (meta-synthesis, grounded theory …). In addition, the specified method must match the one used, which sometimes may not be the case.
If we have answered affirmatively to these three questions, it will be worth continuing and we will move on to the detailed questions. Is the participant selection strategy consistent with the research question and the method used? It must be justified why the selected participants were the most suitable, as well as explain who called them, where, etc. Are data collection techniques used congruent with the research question and the method used? The technique of collecting data (for example, discussion groups) and the registration format will have to be specified and justified. If the collection strategy is modified throughout the study, the reason for this will have to be justified.
Have the relationship between the researcher and the object of research (reflexivity) been considered? It will be necessary to consider if the involvement of the researcher in the process has been able to bias the data obtained and if this has been taken into account when designing the data collection, the selection of the participants and the scope of the study. To finish with the assessment of the rigor of the work, we will ask ourselves if the ethical aspects have been taken into account. It will be necessary to take into account common aspects with quantitative research, such as informed consent, approval by ethical committee or confidentiality of data, as well as specific aspects about the effect of the study on participants before and after its completion.
The next block of two questions has to do with the credibility of the study, which is related to the ability of the results to represent the phenomenon from the subjective point of view of the participants. The first question makes us think if the analysis of the data was sufficiently rigorous. The entire analysis process should be described, the categories that may have arisen from the collected data, if the subjectivity of the researcher has been assessed and how the data that could be contradictory to each other has been handled. In the case that fragments of testimonies of participants are presented to elaborate the results, the reference of their origin must be clearly specified. The second question has to do with whether the exposure of the results was made clearly. They should be presented in a detailed and understandable manner, showing their relationship to the research question. We will review at this point the strategies adopted to ensure the credibility of the results, as well as if the authors have reflected on the limitations of the study.
We will finish the critical assessment by answering the only question of the block that has to do with the relevance of the study, which is nothing more than its usefulness or applicability to our clinical practice. Are the results of the investigation applicable? We will have to assess how the results contribute to our practice, how they contribute to the existing knowledge and in what contexts may they be applicable.
And here we are going to leave it for today. You have already seen that we have taken a look into a world quite different from the one we are more used to, in which we have to change a little the mentality of how to pose and study problems. Before leaving, I have to warn you, as in previous posts, to not to look for fildulastrosis, because you will not find this disease anywhere. Actually, fildulastrosis is an invention of mine in homage to a very illustrious character, sadly deceased: Forges. Antonio Fraguas (from the English translation of his last name comes his nom de guerre) was, in my humble opinion, the best graphic humorist since I have conscience. For many years I began the day seeing the daily Forges’ joke, so since some time there are mornings that one does not know how to start the day. Forges had many own invented words and I really liked his percutoria’s fildulastro, who had the defect of escalporning now and then. Hence comes my fildulastrosis, so from here I thank him and I give him this little tribute.
And now we’re leaving. We have not talked much about other methods of qualitative research such as grounded theory, meta- ethnogarphy, etc. Those interested have bibliography where they are explained in a better way than I could do it. And, of course, as in quantitative research, there are also ways to combine qualitative research studies. But that is another story…