Qualitative Research in Medicine: Methods, Examples & Analysis for IMGs

Introduction

Ask a patient who has uncontrolled diabetes and you’ll receive a number, the level of her HbA1c. Question her and she’ll tell you a story about why she is not taking her metformin at night. It’s a bus ride to the pharmacy. She gets an upset stomach from the tablets. Her neighbour told her that they cause the kidneys to be damaged.

The story is the basis for qualitative medical research. It’s what people feel, think and do, and it fills in the gaps in trials and surveys.

This manual will guide you in the process step by step:

• The nature of Qualitative Research and when it is recommended
• The most common types of study designs.
• How to collect and analyse data, e.g. with an example.
• The student will be able to explain how to write up a study using COREQ or SRQR.

What is Qualitative Research in Medicine? 

Medical research involving the use of qualitative research is medical research that focuses on words, observations and stories instead of numbers to study health and healthcare. The data are the transcriptions of the focus group recordings, the researcher’s notes and interviews.

A quantitative study is an investigation that inquires about quantities or amounts. Qualitative research is used to ask the questions of ‘what’ and ‘why’. You would use it if you wished to:

• See an illness or treatment from the sufferer’s point of view
• Connect with and understand patients/clinicians’ decision-making process
• Investigate an area of a problem not extensively investigated
• Identify concepts that he can investigate in a more comprehensive research project later on.

Qualitative and quantitative work answer different questions, and every project needs to know which one it is asking. What is quantitative research covers the other side: how it is designed, what it measures and where it stops being useful.

Let’s understand this with a quick example: 

What do you do if you find that nearly half your patients aren’t at the follow-up appointment at your clinic? What do you do if you discover from your audit that almost 50% of your patients aren’t showing up at follow-up appointments in your clinic? The audit will not provide an explanation of why. Interviews can. The patient might talk about the cost of the bus, the 3 hours of waiting or the difficulty reading the discharge slip. The clinic has a roadmap for making change.

Counting the missed appointments is usually the easy half, because the numbers already sit in the records. How to do a retrospective chart review covers building that data collection form before you decide what the interviews need to explain.

Why is Qualitative Research Important in Healthcare? 

There are very few situations where patients act as the protocol presumes. How is this the gap, and what are the qualitative reasons for this gap? It is used for research to:

• Emphasize listening to patients’ responses to diagnosis or treatment
• Find out what makes it difficult to access care, e.g. cost, distance of services or stigma
•  Improve the communication and involvement of the doctor & patient in decision-making
• Know the nurse, physicians and other personnel’s difficulties.
•  Determine what makes one hospital successful over another

Implementation research is most important for the last use. The new care pathway may be brilliant in a trial, but fail to ‘take off’ on a busy ward. The team finds out from interviews and observations where it is broken, and then tries to repair it before it is discovered by other sites.

In the healthcare field, there are five methods of qualitative research.In the healthcare field, there are five methods of qualitative research:

The 5 classic ways are outlined below. Select the most appropriate one for the question.

Approach	Purpose	Medical research example
Phenomenology	Understand lived experiences	Experiences of cancer patients
Grounded theory	Develop a theory from collected data	How doctors make clinical decisions
Ethnography	Study cultures and social behaviors	Team dynamics in hospital settings
Narrative inquiry	Explore individual stories	Patient journeys with chronic illness
Case study	Explore a phenomenon in depth within its context	Implementation of a new hospital care model

There’s a simple difference between them; each asks a different question.

• Phenomenology: How does it feel to be living this way?
• Grounded theory: How does what occurs happen? The theory you construct is based on your own data, rather than a theory you bring with you to test.
• Ethnography: What is the culture of this place? Over the course of several weeks, the researcher spends time on a ward or in a clinic, watching.
• Narrative inquiry: How do people tell the story of their illness over time?
• Discuss: A case study about how this one program or team did it in its actual context.

Thematic analysis or content analysis is a study design that often comes up when you’re a beginner. They aren’t designs. Those two, along with the framework method, are methods of analysing data and are housed within most every design. Thematic analysis can be adopted for a case study. Pick the design before the analysis.

A qualitative case study is not a clinical case report, and the two get confused constantly. How to write a medical case report covers the clinical format instead.

How to Design a Qualitative Research Study in Medicine 

The qualitative study requires the same amount of planning as the trial. Follow these steps to work through:

1. Find the problem: Try to find something that is unclear from the numbers, such as low participation in a free screening program.

2. Write an open question: Use “how” and/or “what” questions, such as “How do women in rural districts experience cervical cancer screening? The question “Does X cause Y?” is appropriate for a quantitative study.

3. Match the way of asking the question: Phenomenology is indicated by lived experience. If there’s a process you want to explain, then it is grounded theory.

4. Decide: on who you will be studying and establish inclusion and exclusion criteria.

5. Decide on a sampling method: Most studies employ purposive sampling, generally a selection of individuals that have first-hand experience with the topic. Another form of grounded theory is theoretical sampling, in which initial results help determine who to interview to develop insights.

6. Consider sample size: There’s no formula. Many teams end the interviewing process when nothing new is gained from additional interviews (data saturation). Others go by information power: a thin aim and a well-matched set of players means that you don’t need too many.

7. Draft and submit protocol and ethics application: Discuss the consent, confidentiality and storage of recordings.

Qualitative studies usually carry a research question rather than a hypothesis, and the difference matters when you write the protocol. Research question versus hypothesis covers when each one fits, and the PICO framework covers the PICo and PEO variants that suit qualitative questions.

Methods of Data Collection in Qualitative Medical Research 

Most of the work is done by the following four methods:

• Semi-structured interviews: List of questions; follow up on what the participant says. The standard in medical research.
• Interviews: that are more in-depth and less structured and go into great lengths on a single topic.
• Focus group:  Small group discussion with a moderator to keep the group focused on a topic. Individuals respond to one another, and this can uncover opinions not captured in a one-on-one interview setting.
• Observation: involves noting what actually occurs in a clinic or ward and taking notes of the observations.

Good interview questions are open and do not lead the interview. Compare these two:

• Do you forget your medicine because of being busy? (leading, asking a yes/no question)
• “What was the last time that you forgot a dose? (Open)”

The second one gets a story.

Only record interviews with the subject’s permission and provide a verbatim transcript. Eliminate identifying information such as names and add a code number to each transcript (such as P01) and keep them safely.

How to Analyze Qualitative Data in Medical Research 

Thematic analysis is the most used approach in medical studies, which was developed by Braun and Clarke in 2006. It has six phases:

1. Familiarization with the Data: Read each transcript several times to become familiar with the collected data.

2. Generating Initial Codes: Label meaningful sections of text with codes that describe their content.

3. Searching for Themes: Group related codes to identify broader patterns and emerging themes.

4. Reviewing Themes: Compare each theme against the coded extracts and the entire dataset. Refine, combine, or separate themes where necessary.

5. Defining and Naming Themes: Clearly define and describe each theme to capture its central meaning.

6. Producing the Report: Prepare a detailed report presenting the findings, supported by relevant quotations from participants.

Consider interviews with patients with type 2 diabetes, for example:

Participant response	Initial code	Emerging theme
“I cannot afford my medicines every month.”	Medication cost	Financial barriers
“I sometimes forget my evening dose.”	Forgetfulness	Medication management challenges
“I don’t understand why I need medicines when I feel fine.”	Limited awareness	Knowledge and perceptions

There are two ways of obtaining codes. Inductive coding is deducing codes from data. In deductive coding, the coding is done from an existing theory or framework and the transcripts are searched for it. There are plenty of studies that utilize both of them.

Braun and Clarke later changed their name to reflexive thematic analysis. You’re not just sorting the data, you’re trying to interpret it, so you should tell them that.

NVivo, ATLAS.ti and MAXQDA help you handle hundreds of pages of transcripts. They will arrange your codes, but not provide you with the themes.

Examples of Qualitative Research in Medicine 

Qualitative research is used by nearly all specialties. A few typical topics:

Oncology: What works and what doesn’t when it comes to coping with the side effects of chemotherapy and the kinds of support that help.

Diabetes: Why patients do not take their medicines, whether it be the cost or concerns about side effects, is no different when it comes to diabetes.

A critical care: unit is a specialized hospital department that handles the most serious medical emergencies.A critical care unit is a specialized hospital department that treats the most severe medical emergencies.

Student education: Attitude towards clinical rotations and gaining confidence on wards

The answer in each is in feelings, decisions or social context. It will be levelled by a rating scale. The results can be very practical, too. The study described above may result in a clinic changing to cheaper generics, sending reminders to patients to take their medication by text message, or adapting their patient leaflets.

Qualitative vs Quantitative Research in Medicine

Both methods are equally good. Quantitative research deals with the amount of “how many” and “how much,” whereas qualitative research deals with the amount of “how” and “why.

Feature	Qualitative	Quantitative
Objective	Explore experiences and perceptions	Measure variables and test hypotheses
Data	Non-numerical	Numerical
Sample	Usually smaller, purposively selected	Often larger, depending on design
Collection	Interviews, focus groups, observations	Surveys, experiments, measurements
Analysis	Coding and thematic analysis	Statistical analysis
Findings	Themes, patterns, interpretations	Numerical estimates and associations
Typical question	“How do patients experience dialysis?”	“Does drug X lower blood pressure?”

You don’t always have to choose. Both are employed in mixed-methods studies. A team might run a diabetes application to determine if it is effective at reducing an individual’s HbA1c, and follow up to understand why some patients continued to use it while others discontinued. When the numbers are used first and the interviews are used second, it is known as an explanatory sequential design.

Quality and Trustworthiness in Qualitative Research 

P-values cannot be used to evaluate a qualitative study. Instead, reviewers consider trustworthiness as defined by four criteria by Lincoln and Guba (1985):

• Credibility: Are the findings credible to what participants meant?
•  Dependability: Would someone be able to replicate the procedure of the study?
• Confirmability: Are the findings based on what has been observed in the data, or on assumptions made by the researcher?
• Transferability: Can the reader make a good judgment about how well the setting is described so they can judge if the results will transfer to their setting?

There are some habits that can help meet these. Maintain a reflexive journal of your personal background that can influence your reading. Present findings to participants and invite their comments on the validity of the findings (member checking). Keep an audit trail of all coding decisions. Use more than one data source or coder (triangulation) where possible.

Quantitative studies have their own way of showing how far a result can be trusted. P value versus confidence interval covers what each one tells you and what neither can.

COREQ vs SRQR vs CASP: Qualitative Research Reporting Guidelines 

Each of these three performs a specific function, so they are easily confused:

• From 2007, Tong and colleagues published a 32-item checklist for reporting interview and focus group studies (COREQ). It inquires about the research team, the research design, and analysis.
• SRQR: A 21-item standard from O’Brien et al. (2014) for qualitative research, of all forms.
• CASP: NOT A REPORTING TOOL AT ALL!! It has a qualitative checklist to help with the appraisal of studies published by others.

For interviews and focus groups, use COREQ for your own study; for other designs, use SRQR. Use CASP when the studies you are looking at have been published, for example, in a systematic review. You’ll find COREQ and SRQR on the EQUATOR Network website.

Frequently Asked Questions

Q1. Give an example of qualitative research in medicine.

A team of clinicians speaks with patients with type 2 diabetes to ascertain why they are under-dosing and then types up their answers. Themes such as cost and forgetfulness come out of the analysis.

Q2. What is the number of respondents required for qualitative research?

No fixed number, the number is not fixed. This depends on your question, design and richness of interviews. Most studies conduct sample sizes until saturation, or until they quote information power as the reason.

Q3. Thematic analysis is what?

It’s a way to discover meaning in qualitative information. You code, collate codes into themes and interpret the meaning of the themes.

Q4. Is there a way to integrate qualitative and quantitative research?

Yes, using mixed methods research. The numbers tell what happened; the interviews tell why.

Conclusion

Qualitative research in medical research demonstrates you the people. Ask a broad, open-ended question and allow it to guide your design, sample and analysis.

Need assistance in planning the first qualitative study? The American Academy of Research and Academics (AARA) provides a research method that is taught step-by-step from your initial question to a publishable manuscript.

Sources

1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.
2. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589-597.
3. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357.
4. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251.
5. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753-1760.
6. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage; 1985.
7. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117.
8. EQUATOR Network. Reporting guidelines for qualitative research.
9. Critical Appraisal Skills Programme (CASP). CASP Qualitative Studies Checklist.

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