Vol. 13, Suppl.

1
Printed in Great Britain

Family Practice
Oxford University Press 1996

Qualitative research: the research questions it can

help answer, the methods it uses, the assumptions
behind the research questions and what influences
the direction of research.
A summary of the panel discussion at the
conference 'Exploring qualitative research in
general practice'
Frances Griffiths
This paper describes the themes identified by the editor
from the recording and transcripts of the panel discussion at the conference Exploring qualitative research
in general practice. The editing process was a form of
qualitative analysis in itself. The panel discussion was
based on research questions developed by groups of conference participants during the conference lunch break.
The research questions were selected for discussion by
the panel chairman and panel members. The panel consisted of the conference speakers (DA, SH, MJ, CH,
RJ) and chairman (MM) with other conference participants contributing comments (one contributor could
not be identified from the recording). In this paper the
discussion points made are attributed to the person
speaking by initials following their comment. The text
does not represent exact quotations but the editor has
endeavoured to preserve the essence and meaning of
the comments (FG).
One criterion used in the selection of topics for discussion was whether the group of participants had produced
a question. The panel decided to respond only to questions. We are programmed to look at research as
questions but is research only about questions? (SH).

proached with a qualitative method (DA), but 'what'

questions such as "What are evidence-based
guidelines?" may also use qualitative methods (SH).
People may say that evidence-based guidelines are a
good thing but act differently. To start making sense
of that we need to ask doctors ' 'What do you mean by
evidence?" The behaviour of GPs may be based more
on the evidence of their own experience which is a different notion of evidence from that used in guidelines
(CH). A research question such as "What precipitates
people to present to their GP saying they are tired all
the time?" raises other questions: "What does tiredness
mean?" "Are people more tired now than they were?"
"Has the meaning of tiredness changed?" (SH). The
research question "What does drug-seeking behaviour
really mean?" is a different order of question as it is
trying to find out what drug-seeking behaviour means
in a particular culture or society, rather like asking
"What does going to church mean?" It is a sociological
or anthropological question which cannot be answered
by simply interviewing people. Developing an answer
would involve starting from a particular theoretical
perspective (e.g. Marxism or psychoanalysis) which
may provide some insights, then finding a way of testing
these out (DA). It is possible ask individuals "What
does this mean to you?" The answers may be expressions of the bigger scheme or the individuals may give
interesting idiosyncratic answers of their own. These
answers only make sense against a background of the
themes in society at the time, and those you have to
discover by looking at the media, analysing newspapers,
etc. (CH). To begin to answer the question "Do patients and GPs both want the same thing out of general
practice?", the.different meanings and assumptions of
two groups in society, doctors and patients, would have
to be investigated . The question indicates the clash of
two cultures but we do not know enough about them,
it would be complex to investigate and the question as
phrased is probably too big to get started (CH).

Research questions that qualitative

methods can help answer
Qualitative methods may provide useful tools for
understanding phenomenon for which, at present, we
have no really good working models, for example, why
people do not take prescribed drugs as intended by the
doctor (MM). 'Why' questions such as "Why do GPs
not implement evidence-based guidelines?" are best ap-

Norton Medical Centre, Harland House, Norton, Stockton-on-Tees

TS20 IAN, UK.

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Family Practicean international journal

Methods used in qualitative research

This way the person interviewed can be more relaxed

as they are not talking about themselves but projecting
onto the story (CH). Interviews have to aim at finding
out about things that are accessible to the person interviewed. If you asked a GP "What do you want from
general practice?" you might get a public or pat answer,
but it would be too general to be of value in the research.
The question would have to be broken down as you can
only find out what people can make sense of themselves
(DA).
A group interview could be used to develop, for example, a list of priorities for quality standards in general
practice. The results from a group of GPs and a group
of patients could be compared to see how much they
match (RJ). A Balint group is a special form of group
research which could look at when and why doctors
follow evidence-based guidelines or not, and tease out
some of the detail of this. Being from a different
discipline, the psychoanalyst in the Balint group has the
important role of heightening perception and observation to help the group see what is at that moment beyond
the field of vision (SH).
Observational studies can reveal the reality behind
the rhetoric. For example a research question about the
primary health care team may see the team as a group
of professionals co-operating with each other. However,
the members of the team come from a number of different professional subcultures. It would be interesting
to do a flynon-the-wall observation to see how things
actually worked (CH).
Written material has been mentioned as a source of
data about the prevailing culture. In trying to answer
a research question such as 'What does tiredness mean?'
in a literate society, looking at printed material such
as newspapers and women's magazines is important in
revealing the wider cultural themes. Doing this reveals
a whole series of so-called depletion diseases based on
mechanical metaphor such as 'running on empty' 'at
a low ebb' 'drained' (CH). The historical study of a
question about a symptom such as tiredness may use
a series of medical texts, of which there are many from
the eighteenth century onwards. A historian might look
at the way words are used in certain contexts such as
fatigue, as used by a psychiatrist or a pathologist.
Newspapers and personal diaries or correspondence,
if available, can also be used. However, historians are
wary of seeing continuity in the use of, for example,
diagnoses over time. To use the example of learning
difficulties, historians would argue that it is difficult
to be sure whether a diagnosis based on a number of
symptoms made in the nineteenth century, such as
feeble-mindedness, is the same as what we are talking
about now in terms of learning difficulties (MJ).

A research question can be looked at from different

angles and using different methods to provide different
types of answer. This notion of triangulation can result
in stronger and better research tools (MM). The different methods may be qualitative, quantitative or a mixture. A population survey may reveal the frequency of
a symptom such as tiredness and how many people
consult their doctor about it. To understand why some
people go to see their doctor and others do not, some
of those that attend the doctor and some that do not could
be interviewed (RJ).
An interview study can take many forms. One of the
commonest used is the semi-structured interview where
the interviewer has a schedule of areas to cover. Interviews of doctors about evidence-based guidelines may
include "Have you heard of evidence-based
guidelines?" "Do you know what in your clinical practice is based on evidence?" "Do you apply guidelines,
when and where?" (DA). However, if the interview
subjects are GPs, can a GP be the interviewer? One
view is that you cannot study your own tribe because
there is too much hidden culture and assumptions. The
researcher needs to ask innocent questions to uncover
this. However, there can be good and bad interviewers
from all disciplines, it is partly a question of technique. A GP interviewing GPs will give a different interview and get a different story from a social scientist
interviewer, but who is to say that one story is going
to be more interesting or rewarding than the other?
(CH).
There are specific techniques that can be used within
interviews to enhance the research data. For example,
a research question about being tired all the time is using,
what is know as standardized language of distress. All
of life's problems from unemployment to marital problems come in the phrase 'tired all the time'. To work
outwards from this label you could use free-association,
asking question such as ' 'What do you mean by tired?''
''What do you mean by all the time?" ''What do people
who are not tired look like?" When looking at any condition it can be very revealing to ask about the exact
opposite. If you ask someone taking diazepam "What
effect does diazepam have on you when you take it?"
the reply may be "Oh it does not have any effect".
Asking "What would happen if you did not have
diazepam?" would give a different series of answers.
A different technique could be used for a research question, such as "What are the images which GPs have
of themselves and their roles?" If you ask a doctor
''How do you see your role?" they are likely to freeze
up as the question is so open-ended. One way around
this would be using projective techniques. You could
give them a series of scenarios, each one a description
of what a GP does, and ask them which they most identify with, or give them a story of a GP and ask them
to tell you about the doctor written about in the story.

Health diaries have been used in the past to research

illness behaviour but were dropped because of
methodological difficulties. Patients would not complete
them as they claimed they made them feel ill (DA).
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Qualitative research; a discussion

improving and mortality rates declining, there were certain sections of the population in certain parts of the
country who were not benefiting from declining mortality rates. By asking 'Why did mortality rates decline?'
you are avoiding a whole set of issues about health,
medicine and disease in society (MJ).

Recently they have been used successfully in conjunction with interviews for looking at help-seeking
behaviour. The diaries acted as an aide-memoir in the
interviews, a blank entry sometimes reminding the
person interviewed of what happened that day, such as
a child falling out of a tree (?). A variation on this
method is to ask people, for example, those that say
they are 'tired all the time', to write a story about how
they came to be tired all the time (CH). This method
has also been used therapeutically (PC). In the eighteenth century a doctor attending a rich patient would
ask the patient to transcribe their own experience and
symptoms. The diagnosis was then negotiated between
them, partly as the patient and doctor were considered
equals. This was before what Foucault refers to as the
development of a clinical gaze and the patient becoming an object that can be studied (MJ).

Influences on the direction of our

research
A researcher's experience and background will influence the way a research project develops; however,
a much greater constraint on what research questions
are tackled and how, is the availability of funding.
Research has to be related to policy and has to be in
the area of interest of the grant-giving bodies. This constraint is greater now that the big sums of research
money are centrally controlled (RJ). Grant-giving bodies
help create the culture that shapes the whole research
enterprise and, in a sense, it has been ever thus. Major
paradigms capture the research market for long periods
of time (MM). The challenge is to get involved with
the policy development of these grant-giving bodies
(RJ).
A problem for researchers, particularly in health service research, is that the questions we ask change before
we answer them. There is a move towards research for
quick decision-making where, rather than seeking a
global answer to a research question, we do a short,
focused, non-generalizable project, often with a mixture of research methods, to answer a specific health
service problem. This process may emerge in the future
as an important research paradigm and with this form
of research the issues about generalizability would cease
to matter (RJ).
The research question about the use of evidence-based
guidelines leads to a historical question about why
evidence-based medicine has become so prominent now
(RB). The basic medical sciences that emerged from
the late nineteenth century have made a dramatic difference to diagnosis and treatment of certain medical
conditions, and this is part of their legitimating power.
This medical science is perceived by doctors and patients and, until the last 10-20 years, was perceived by
the media as a major contribution to society. However,
some of this optimism is beginning to dissolve, and part
of this process is the challenge made by the legal profession, through law suits, and by the media, to the
cultural supremacy of medical science. One of the
reasons why experimentalism, bio-genetics, bioreduction is so potent now is because it is a reaction
to some of that criticism and to those external forces
trying to undermine the practice of medicine. Historians
would see this process as a series of negotiations with
the professional groups and different interests constantly
shifting position (MJ).

The assumptions behind the research

questions
A research question such as 'Are there limits to skill
substation in primary care?' is about nurses taking on
new roles, GPs delegating certain tasks and perhaps
taking on other ones. However, there seems to be an
agenda here about how different health care workers
feel about changing roles and tasks. The question may
have started as a statement 'There are limits . . .' (MM).
What does 'limits' mean? Does it mean 'Are there limits
to potential?' or does it mean 'Who is setting up barriers?' The question makes an assumption that there are
limits (SH). Behind the question 'What does drugseeking behaviour really mean?' there seems to be an
agenda about whether we approve of drug taking or not.
There is a lot of feeling behind the questions we ask,
they are not innocent they are knowing and are not so
much questions as statements of a point of view. All
facts, all data are values. For example, a researcher
may have some feelings about evidence-based medicine
that may affect the way in which the researcher sets
about the research. Are we able to distinguish the value
system in which we approach these questions and the
type of research we do? (MM)
A historian, if asked a question such as 'Why did
mortality rates change in the twentieth century' would
want to ask further questions, such as, 'Did they
change?' 'Where does the evidence come from?' 'Who
compiled the statistics?' and 'How and what do they
tell us about groups within the population as well as
the whole?' During the 1930s, for example, the rhetoric
from public health officials and the government was
that mortality rates were declining and standards of living were improving, but fairly close historical study
of the figures they quoted suggests that, although in the
population as a whole standards of health may have been
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Family Practicean international journal

Our training as doctors has led us to trust experimental

results or results of research based on large population
samples and to lose our trust of our own perceptions
and experiences. The word 'anecdotal' has become a
sort of swear word, yet what is wrong with anecdotes?
Some of the greatest breakthroughs in history have been
made from anecdotes. As GPs and general practice
researchers we have to develop trust in our own perceptions and the perceptions of others (CH).

Yet in the last 50 years one of the most major changes

in health service provision in this country was the
closure of psychiatric hospitals, and one of the key
determinants of that was a qualitative study (DA).1
Whenever you look at the history of research you find
that researchers have suddenly broken through a barrier and shown us something which we really did not
see before. The question for medicine, and in particular
for everyday general practice, is what is staring us in
the face now that we just cannot see. Answering that
question seems to be the exciting possibility for the kind
of research approaches that have been discussed in this
conference (MM).

Conclusion
Qualitative research is not an ultimate pathway to truth,
but it is useful and can reach parts that other forms of
research cannot (CH). At present, qualitative methods
may be viewed as at the bottom of a hierarchy of
methods with randomized controlled trials at the top.

Reference
1

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Goffinan E. Asylums. Essays on the social situation of mental

patients and other inmates. Hannondsworth: Penguin, 1968.