Qualitative research in health: value and visibility

The values of qualitative research in health policy planning and development, health services organisation and delivery, and enhancing the understanding of comprehensive health interventions have been increasingly recognised over the past two decades.1Williams V. Boylan A. Nunan D. Qualitative research as evidence: expanding the paradigm for evidence-based healthcare.BMJ Evid Based Med. 2019; 24: 168-169Crossref PubMed Scopus (17) Google Scholar, 2Daniels K. Loewenson R. George A. et al.Fair publication of qualitative research in health systems: a call by health policy and systems researchers.Int J Equity Health. 2016; 15: 1-9Crossref PubMed Scopus (25) Google Scholar, 3Jones R. Strength of evidence in qualitative research.J Clin Epidemiol. 2007; 60: 321-323Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar Qualitative research seeks to, in its nature, explore and/or explain the phenomena in the real world, which shape or are shaped by human perspectives, experiences, and wider political, social, and cultural contexts. For health system strengthening, this is an appropriate method to understand “how” norms and stakeholders influence the design and function of health systems, “why” intended outcomes are achieved or are not achieved, and “what” the unintended outcomes are. In 2016, an open letter from Trisha Greenhalgh and other 75 senior academics from 11 countries to the editors of The BMJ4Greenhalgh T. Annandale E. Ashcroft R. et al.An open letter to the BMJ editors on qualitative research.BMJ. 2016; : 352Google Scholar triggered a wide debate on the value of and publication bias in qualitative research.2Daniels K. Loewenson R. George A. et al.Fair publication of qualitative research in health systems: a call by health policy and systems researchers.Int J Equity Health. 2016; 15: 1-9Crossref PubMed Scopus (25) Google Scholar,5Toews I. Glenton C. Lewin S. et al.Extent, awareness and perception of dissemination bias in qualitative research: an explorative survey.PLoS One. 2016; 11e0159290Crossref Scopus (23) Google Scholar The bibliometric analysis suggested the low proportion of original qualitative research in healthcare published in health journals,6Mori H. Nakayama T. Academic impact of qualitative studies in healthcare: bibliometric analysis.PLoS One. 2013; 8e57371Crossref Scopus (22) Google Scholar,7Shuval K. Harker K. Roudsari B. et al.Is qualitative research second class science? A quantitative longitudinal examination of qualitative research in medical journals.PLoS One. 2011; 6e16937Crossref PubMed Scopus (58) Google Scholar and the publication was significantly associated with journals’ policies expressed through the specific instructions for authors and editorial/methodological papers on the subject.6Mori H. Nakayama T. Academic impact of qualitative studies in healthcare: bibliometric analysis.PLoS One. 2013; 8e57371Crossref Scopus (22) Google Scholar The analysis also revealed that UK journals had a higher proportion of published qualitative studies, and that authors from English-speaking countries cited qualitative studies more frequently.6Mori H. Nakayama T. Academic impact of qualitative studies in healthcare: bibliometric analysis.PLoS One. 2013; 8e57371Crossref Scopus (22) Google Scholar,7Shuval K. Harker K. Roudsari B. et al.Is qualitative research second class science? A quantitative longitudinal examination of qualitative research in medical journals.PLoS One. 2011; 6e16937Crossref PubMed Scopus (58) Google Scholar This phenomenon may imply the disparity in research tradition, culture, and training system across different countries. The arguments for infrequently publishing qualitative studies may center on less familiar qualitative research methods, challenges in appraising the quality of qualitative research, and inadequate reporting quality. Qualitative research allows for theoretical and methodological flexibility, which is its strength to deeply explore and understand the context specificity of the study questions. Standardised randomised controlled trials may examine the effectiveness of comprehensive health intervention, while qualitative research can be the most suitable approach to exploring health needs, understanding the complexity of intervention implementation, and supporting knowledge translation and adaptation in specific settings. There is guidance for qualitative research, but no “recipes”. The quality and rigor of qualitative studies demands inter- and multi-disciplinary assessment of the rationale for a qualitative design, sampling details, data collection and analysis, research team and reflexivity (refers to researchers self-conscious of their own influence on the research process and interpretation) as well as ethical considerations.8Kuper A. Reeves S. Levinson W. An introduction to reading and appraising qualitative research.BMJ. 2008; 337Crossref Scopus (355) Google Scholar,9Rendle K.A. Abramson C.M. Garrett S.B. Halley M.C. Dohan D. Beyond exploratory: a tailored framework for designing and assessing qualitative health research.BMJ Open. 2019; 9e030123Crossref PubMed Scopus (42) Google Scholar Unsurprisingly, some scholars and health professionals may find it difficult to distinguish good from poor qualitative research given the epistemological diversity. In addition, qualitative research training is not to the same extent as the long tradition of quantitative studies in the area of health services research. Over the past decades, leading medical journals, like The BMJ and The Lancet, and the health services research society published educational series, methodological papers, and appraisal standards (in terms of diverse theoretical orientations and approaches) on qualitative research aiming to improve qualitative research literacy in the community. Based on the 22 existing checklists and guidelines for reviewing and reporting qualitative studies, Allison Tong and colleagues developed a 32-item checklist, Consolidated Criteria for Reporting Qualitative Studies (COREQ) to support transparency in qualitative research methods.10Tong 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: 349-357Crossref PubMed Scopus (14659) Google Scholar Nevertheless, the low priority of disseminating qualitative studies may prolong the efforts of recognising its value and undermine interest in funding and conducting qualitative research, particularly in low- and middle-income countries due to insufficient training and capacity to carry out this type of research. To promote the dissemination of meaningful and impactful qualitative evidence for health, continued efforts for education and capacity building of conducting, reporting, and appraising high-quality qualitative studies are needed. The application of the qualitative approach in health-related research should be considered to integrate into medical and public health training curricula. The areas of health services research, health policy, and system research often encourage multi-disciplinary collaboration. The research team could ensure qualitative expertise throughout the lifespan of the study (from the study design to results dissemination) to enhance validity, reliability, and transparency in implementing and reporting qualitative study. This also provides the training opportunity to strengthen the research capacity in qualitative and mixed-methods studies through research cooperation, especially for young researchers in low- and middle-income countries. Similarly, the academic community may assist the journal editors to invite guest editors and reviewers with qualitative expertise. Increased openness to scientifically sound qualitative studies in prominent medical and public health journals will serve as a significant signal of progress and provide learning platforms for advancing the understanding of the strength of qualitative evidence in health. QL conceived and drafted the manuscript. HJ commented and edited the manuscript. The authors declare that they have no competing interests. Funding: None.