research and family practice may be a marriage made in
heaven,27 Collings failed to establish the legitimacy of
ethnography as a form of scientific inquiry. Within
general practice Collings is remembered not for his
contribution to research methods but for the revival of
the specialty. At the same time (doubtless because it
was published in a medical journai) his study has been
neglected by historians of social research. As a result,
Collings has failed to attract the consideration he
deserves as a pioneer ofBritish ethnography.
I thank the anonymous reviewers of an earlier draft of the
manuscript for their constructive criticisms.
Source offunding: This research was unfumded.
Conflicts ofinterest: None.
1 Collings JS. General practice in England today: a reconnaissance. Lancet
2 HartJT.A new kind ofdoctor. London: Merlin, 1988.
3 Loudon I. The concept of the family doctor. Buletin of the History ofMedicine
4 Gray DP. Forty years on: the story of the first forty years of the Royal College of
GeneralPractitioners. London: Atalink, 1992.
5 Hunt JH. The scope and development of general practice in relation to other
branches ofmedicine: a constructive review. Lancet 1955;ii:681-6.
6 Webster C. The health servsces since the war. Vol 1. Problems of health care: the
NationalHealth Service before 1957. London: HMSO, 1988.
7 Hunt JH. The foundation of a College: the conception, birth, and early days
ofthe Coilege ofGeneral Practitioners. Journal ofthe Royal Colege ofGeneral
8 Nuffield Provincial Hospitals Trust. The hospital surveys-the Domesday Book
ofthe hospital services. Oxford: Oxford University Press, 1945.
9 Honigsbaum F. Health, happiness and security: the creation of the National
Health Semice. London: Roudedge, 1989.
10 Taylor S. Goodgeneralpractice. Oxford: Oxford University Press, 1954.
11 McLachlan G. A history of the Nuffield Provincial Hospitals Trust, 1940-1990.
London: Nuffield Provincial Hospitals Trust, 1992.
12 Nuffield Provincial Hospitals Trust. Second report. Oxford: Oxford University
13 Bazerman C. Shaping written knowledge. Madison: University of Wisconsin
14 Smith HV, Vollum RH. Effects of intracathecal tuberculin and streptomycin
in tuberculous meningitis. Lancet 1950;ii:275-86.
15 Anonymous. The GP at the crossroads[editorial).BMJ 1950;i:709-13.
16 Hannerz U. Exploring the city: inquiries towards an urban anthropology. New
York: Columbia University Press, 1980.
17 Harrison T. The future ofsociology. Pilot Papers 1947;2:10-25.
18 Stacey M. Tradition and change: a study ofBanbury. Oxford: Oxford University
19 Wiliams WM. The sociology ofan English village: Gosforth. London: Routledge
and Kegan Paul, 1956.
20 FrankenbergR Village on the border. London: Cohen and West, 1957.
21 Payne G, Dingwall R, Payne J, Carter M. Sociology and social research.
London: Routledge and Kegan Paul, 1981.
22 Roethlisberger FJ, Dickson WJ. Managemnent and the worker. Cambridge, MA:
Harvard University Press, 1939.
23 Lupton T. On the shopfloor. London: Pergamon, 1963.
24 Cunnison S. Wages andwork allocation. London: Tavistock, 1966.
25 Dingwall R. Research note: thirty years on. Sociology of Healh and Ilness
26 Honigsbaum F. The division in British medicine. London: Kogan Page, 1979.
27 Murphy EA, Mattson B. Qualitative research and family practice: a marriage
made in heaven? Fam Pract 1992;9:85-91.
(Accepted 9March 1995)
This is thefirst ofseven articles
techniques andshowing their
value in health research
Health, University of
Leicester, 22-28 Princess
Catherine Pope, lecturerin
social and behavioural
King's Fund Institute,
Reaching the parts othermethods cannot reach: an introduction to
qualitative methods in health and health services research
Catherine Pope, NickMays
Qualitative research methods have a long history in
the social sciences and deserve to be an essential
component in health and health services research.
Qualitative and quantitative approaches to research
tend to be portrayed as antithetical; the aim ofthis
series of papers is to show the value of a range
of qualitative techniques and how they can comple-
ment quantitative research.
Aims ofthis series
Medical advances, increasing specialisation, rising
patient expectations, and the sheer size and diversity of
health service provision mean that today's health
professionals work in an increasingly complex arena.
The wide range ofresearch questions generated by this
complexity has encouraged the search for new ways of
conducting research. The rapid expansion of research
on and about health and health services, and the
relatively recent demarcation of a distinct field of
"health services research" depend heavily on doctors
and other health professionals being investigators,
participants, and peer reviewers. Yet some ofthe most
important questions in health services concern the
organisation and culture of those who provide health
care, such as why the findings of randomised con-
trolled trials are often difficult to apply in day to day
clinical practice. The social science methods appro-
priate to studying such phenomena are very different
from the methods familiar to many health profes-
Although the more qualitative approaches found in
certain of the social sciences may seem alien alongside
the experimental, quantitative methods ilsed in clinical
and biomedical research, they should be an essential
component of health
because they enable us to access areas not amenable to
quantitative research, such as lay and professional
health beliefs, but also because qualitative description
is a prerequisite of good quantitative research, par-
ticularly in areas that have received little previous
investigation. A good example ofthis is the study ofthe
social consequences of the application of new genetic
techniques to screening for genetic disease.' New
genetic technologies place individuals, couples, and
families in novel circumstances facing unprecedented
decisions about such things as reproduction, trans-
mission of genetic defects, and the response to infor-
mation about predisposition to particular diseases.
The starting point for social research in this field is
therefore an attempt to understand how and why
people conceptualise genetic
behave as they do when faced with them.
The aim of this series is to introduce some of the
main qualitative research methods currently used in
health care research and to indicate how they can be
appropriately and fruitfully employed. The papers
review observation, in depth interviews, focus groups,
consensus methods, and case studies, all of which
doctors and other health professionals are increasingly
coming into contact with. We hope that by making
clear what these methods entail, how they are used,
and how they can be evaluated, they will seem less
strange and be viewed as valuable tools in the methodo-
logical tool box ofhealth and health services research.
The papers on specific qualitative methods are pre-
ceded by a paper on validity and reliability in qualita-
tive research. Box 1 provides short definitions of some
of the terms used in qualitative research which appear
in the papers in the rest ofthe series.
Although relatively uncommon in health services
research, qualitative methods have long been used in
risks and why they
the social sciences. Social anthropology, for example,
was founded on studies in which an understanding of
the customs and behaviour of people from remote
lands was gathered by researchers who spent time
living in those societies, often learning their languages
so they could participate while observing. In a similar
way, these naturalistic methods-in essence, watching,
joining in, talking, and reading about the group being
studied-are used by qualitative sociologists to study
the familiar: our own society. Health care is just one
area where these techniques have been applied to study
subjects such as the organisation of health services,
interactions between doctors and patients, and the
changing roles ofthe health professions.
What are qualitative methods?
TIhe common feature of the methods discussed in
this series is that they do not primarily seek to provide
quantified answers to research questions. So what
exactly do they aim to do? The goal of qualitative
research is the development of concepts which help us
to understand social phenomena in natural (rather than
experimental) settings, giving due emphasis to the
meanings, experiences, and views of all the partici-
pants. As a result they are particularly suited, for
example, to understanding how
education messages on stopping smoking can be well
known to teenagers oryoung working class women but
not perceived as relevant to their everyday lives.23
Qualitative studies are concerned with answering
questions such as 'What is X and how does X vary in
different circumstances, and why?" rather than "How
many Xs are there?" Since qualitative research does
not generally seek to enumerate, it is viewed as the
antithesis of the quantitative method; indeed, the two
approaches are frequently presented as adversaries in a
methodological battle. This view is often reinforced by
highlighting a corresponding split in social theory
between theories concerned with delineating social
and those interested
social action or meaning. Box 2 presents a caricature
of the differences between qualitative and quantita-
tive methods in the social sciences which are often
marshalled as evidence of the essential incompatibility
ofthe two approaches.
The randomised controlled trial, with its focus on
hypothesis testing through experiment controlled by
means ofrandomisation, can be seen as the epitome of
the quantitative method. Answering the "what is X"
question, though, is the foundation of quantification:
until something is classified it cannot be measured.
Moreover, because health care deals with people and
people are, on the whole, more complex than the
subjects of the natural sciences, there is a whole set of
questions about human interaction and how people
interpret interaction which health professionals may
are less well suited to answer these questions.
Consider an example from research on diabetes.
There can be no doubt that quantitative methods,
including randomised controlled
tributed to advances in the treatment of this disease.4
As well as knowing that glycaemic control is effective
in reducing long term complications, health profes-
sionals may need answers to additional questions-for
example, those concerned with patient behaviour. For
a general practitioner, knowing that intensive insulin
therapy works may be secondary to knowing whether
the patient will comply with the treatment. This is
where qualitative research can be useful. Indeed, there
is a body of work which examines and explains why
patients do not complywith treatment regimens.5
The rigid demarcation of qualitative and quantita-
tive research as opposing traditions that is shown in
box 2 does not encourage movement or interaction
between the two camps. In effect, researchers on either
side become entrenched and are often ignorant ofeach
other's work. Within sociology there is a growing
recognition that the quantitative-qualitative distinc-
tion has created an unnecessary divide, and this has
done little to assist the progress of the discipline.6
In health services research the differences between
qualitative and quantitative methods continue to be
overstated and misunderstood.7
The dichotomy described in box 2 suggests that
whereas quantitative methods aim for reliability (that
is, consistency on retesting) through the use of
tools such as standardised questionnaires, qualitative
methods score more highly on validity, by getting at
how people really behave and what people actually
mean when they describe their experiences, attitudes,
and behaviours. In addition, the reasoning implicit in
qualitative work is held to be inductive (moving from
observation to hypothesis) rather than hypothesis
testing or deductive. For example, much methodo-
logical writing in the qualitative tradition emphasises
that in order to get behind respondents' formal public
statements and behaviour to uncover their personal
perceptions and actual day to day actions,
it is that health
trials, have con-
Box 1-Glossary ofterms usedin the series
Epistemology-theory of knowledge; scientific study which deals with the nature and
Naturalistic research-non-experimental research in naturally occurring settings
Social anthropology-social scientific study of peoples, cultures, and societies;
particularly associated with the study oftraditional cultures
Induction-process of moving from observations/data towards generalisations, hypo-
theses, or theory; grounded theory-hypothesising inductively from data, notably
using subjects' own categories, concepts, etc; opposite of deduction, process of data
gathering to test predefined theory or hypotheses
Purposive or systematic sampling-deliberate choice of respondents, subjects, or
settings, as opposed to statistical sampling, concerned with the representativeness of a
sample in relation to a total population. Theoretical sampling links this to previously
developed hypotheses or theories
Fieldnotes-collective term for records of observation, talk, interview transcripts, or
documentary sources. Typically includes a field diary which provides a record of the
chronological events and development of research as well as the researcher's own
reactions to, feelings about, and opinions ofthe research process
Content analysis-systematic examination of text (field notes) by identifying and
grouping themes and coding,
comparison-iterative method of content analysis where each category is searched for
in the entire data set and all instances are compared until no new categories can
be identified. Analytic induction-use of constant comparison specifically in develop-
ing hypotheses, which are then tested in further data collection and analysis
Triangulation-use of three or more different research methods in combination;
principally used as a check ofvalidity
Observation-systematic watching of behaviour and talk in naturally occurring
settings. Participant observation-observation in which the researcher also occupies a
role or part in the setting in addition to observing
In depth interviews-face to face conversation with the purpose of exploring issues or
topics in detail. Does not use pre-set questions, but is shaped by a defined set of topics
Focus groups-method of group interview which explicitly includes and uses the
group interaction to generate data
Consensus methods include Delphi and nominal group techniques and consensus
development conferences. They provide a way of synthesising information and
dealing with conflicting evidence, with the aim of determining extent of agreement
within a selected group
Case studies focus on one or a limited number of settings; used to explore
contemporary phenomenon, especially where complex interrelated issues are involved.
Can be exploratory, explanatory, or descriptive or a combination ofthese
Validity-extent to which a measurement truly reflects the phenomenon under
Hawthorne effect-impact of the researcher on the research subjects or setting,
notably in changing their behaviour
Reliability-extent to which a measurement yields the same answer each time it is used
classifying, and developing
important not to impose a priori categories and
concepts from the researcher's own professional know-
ledge on to the process of data collection. Rather
than starting with a research question or a hypothesis
that precedes any data collection, the researcher is
encouraged not to separate the stages of design, data
collection, and analysis, but to go backwards and
forwards between the raw data and the process of
conceptualisation, thereby making sense of the data
throughout the period ofdata collection.8
In the methodological debate, these distinctions are
frequently presented as clear cut, but the contrasts are
more apparent than real. In health services research,
because of its applied nature, much research is driven,
not by the theoretical stance ofthe researcher, but by a
specific practical problem which is turned into a
research question. As Brannen notes, "There is no
necessary or one to one correspondence between
epistemology and methods."9 As she suggests, the
choice ofmethod and how it is used can perfectly well
be matched to what is being studied rather than to
the disciplinary or methodological leanings of the
researcher. It is therefore possible to envisage deduc-
tive pieces ofqualitative research.
How can qualitative methods complement
It would seem more fruitful for the relation between
qualitative and quantitative methods to be charac-
terised as complementary rather than exclusive. There
are at least three ways in which this can be achieved.
Firstly, as noted above, qualitative work can be
conducted as an essential preliminary to quantitative
research. Qualitative techniques such as observation,
in depth interviews, and focus groups (which are
covered in subsequent papers in this series) can be used
to provide a description and understanding of a
situation or behaviour. At their most basic, these
techniques can be used simply to discover the most
comprehensible terms or words to use in a subsequent
survey questionnaire. An excellent recent example of
this was the qualitative research conducted to establish
which sexual terms would be most appropriate to use in
the British national survey of sexual attitudes and
lifestyles.10 This work highlighted several ambiguities
and misunderstandings. "The meaning ofmany terms
-'vaginal sex', 'oral sex', 'penetrative sex', 'hetero-
sexual'-was unclear to a sizeable enough number of
people to threaten substantially the overall validity of
The second way qualitative methods can be used is
to supplement quantitative work. This can be part of
the validation process, as in "triangulation,"'" where
three or more methods are used and the results
compared for convergence (for example, a large scale
survey, focus groups, and a period of observation), or
as part of a multimethod approach which examines a
particular phenomenon or topic on several different
levels.9 This is not simply a matter of joining two
techniques, or tacking one on the end of a project.
Researchers need to be aware of the different types of
answers derived from different methods. Cornwell's
work looking at the health offamilies in the east end of
London was able to distinguish powerfully between
the public and private accounts provided by respond-
ents.12 Though a survey may pick up the public
account, a series of in depth interviews are needed to
get at the private, often contradictory and complex
beliefs people hold. This theme is pursued by Britten
in the fourth paper in this series. It would be invidious
to suggest that one or the other source was the more
valid; suffice it to say that different research settings
and different methods allow access to different levels of
knowledge. None the less, combining methods can
help to build a wider picture, and this is especially
productive when used to explore the findings of
previous research, such as the observational examina-
tion of the surgical decision making process by Bloor
et al, which built on an epidemiological study of the
widespread variations in the rates of common surgical
procedures (box 3).13
The third way in which qualitative research can
complexphenomena or areas not amenable to quantita-
tive research. The value of this sort of stand alone
qualitative research is increasingly widely recognised
in studies ofhealth service organisation and policy.14 It
1 juLY 1995
Box2-The overstateddichotomy between quantitative and
qualitaive social science
What is X? (classification)
Howmany Xs? (enumeration)
Box3-Two stage investigation ofthe
associationbetween differences in
geographic incidence ofoperations on the
tonsils and adenoids and local differences
in specialists' clinical practices'3
I Epidemiologicalstudy-documenting varisations
Analysis of 12 months' routine data on referral,
acceptance, and operation rates for new patients
under 15 years in two Scottish regions known to
have significantly different 10 year operation
rates for tonsils and adenoids.
Found significant differences between similar
areas within regions in referral, acceptance, and
operation rates that were not explained by
Operation rates influenced, in order of import-
* Differences between specialists in propensity
to list for operations
* Differences between GPs in propensity to
* Differences between areas in symptomatic
II Sociological study-explaining how and why
variations come about
Observation of assessment routines undertaken
in outpatient departments by six consultants in
each region on a total of493 under 15s.
Found considerable variation between special-
procedures and decision rules), which led to
differences in disposals, which in turn created
local variations in surgical incidence.
"High operators" tended
spectrum of clinical signs as important and
tended to assert the importance of examination
findings over the child's history; "low operators"
gave the examination less weight in deciding on
disposal and tended to judge a narrower range
of clinical features as indicating the need to
ma be esEcill useflinlokn athatevcsi Download full-text
times ofreform or policy change from the point ofview
of the patients, professionals, and managers affected.
At the end of this senies, Keen and Packwood provide
one example ofhow qualitative methods can be used to
examine the consequences of changes in resource
allocation and management practices at the micro level
within NHS hospitals. In addition, qualitative work
can reach aspects of complex behaviours, attitudes,
and interactions which quantitative methods cannot.
As a result it has been extremely useful for examining
clinical decision making by probing and exploning both
the declared and the implicit or tacit routines and rules
which doctors use.'1516
In this senies the aim is to show how qualitative
methods can, and do, ennich our knowledge of health
and health care. It is not that qualitative methods
are somehow superior to quantitative ones-such
a position merely perpetuates the quantitative-qualita-
tive dichotomy-but that we need a range of methods
at our fingertips ifwe are to understand the complexi-
ties ofmodem health care. "What is involved is not a
crossroads where we have to go left or right. A better
analogy is a complex maze where we are repeatedly
faced with decisions, and where paths wind back on
one another. The prevalence ofthe distinction between
qualitative and quantitative method tends to obscure
the complexity of the problems that face us and
threatens to render our decisions less effective than
they might otherwise be."'7
Patton MQ. Qualitative evaluation and research methods. London:
Bryman A. Quality and quantity in social research. London: Unwin
1 Michie S, McDonald V, Marteau T. Understanding responses to predictive
genetic testing: a grounded theory approach. Psychology and Health (in
2 Amos A, Currie C, Hunt SM. The dynamnics and processes of behavioural
change in five classes of health related behaviour: findings from qualitative
research. Health Education Research 1991,6:443-53.
3 Graham H. When fife's a drag: women smoking and disadvantage. London:
4 Diabetes Control and Complications Trial Research Group. The effect of
intensive treatment of diabetes on the development oflong-term complica-
tions in insulin-dependent diabetes mellitus. N Engi Y Med 1993;329:
5 Morgan M, Watkins C. Managing hypertension: beliefs and responses to
medication among cultural groups. Sociology of Health and Ilness 1988;10:
6 Abell P. Methodological achievements in sociology over the past few decades
with special reference to the interplay of qualitative and quantitative
methods. In: Bryant C, Becker H, eds. What has sociology achieved London:
7 Pope C, Mays N. Opening the black box: an encounter in the corridors of
health services research. BMJ 1993;306:315-8.
8 Bryman A, Burgess R, eds. Analysing qualitative data. London: Routiedge,
9 Brannen J, ed. Mixing methods: qualitative and quantitatve research. Aldershot:
10 Wellings K, Field J, Johnson A, Wadsworth J. Sexual behaviour in Britain: the
national survey of sexual attitudes and lifestyles. Harmondsworth: Penguin,
11 Denzin N. The research act. London: Buttterworth, 1970.
12 CornwellJ. Hardearned lives. London: Tavistock, 1984.
13 Bloor MJ, Venters GA, Samphier ML. Geographical variation in the incidence
ofoperations on the tonsils and adenoids: an epidemiological and sociological
investigation.JLaryngol Otol 1976;92:791-801, 883-95.
14 Pollitt C, Harrison S, Hunter DJ, Marnoch G. No hiding place: on the
discomforts of researching the contemporary policy process. Journal of
15 Silverman D. Communcation andmedicalpractice. London: Sage, 1987.
16 Strong P. The ceremonial orderofthe cinic. London: Routdedge, 1979.
In: Brannen J, ed. Mixing methods: qualtative and quantitative researck
Aldershot: Avebury, 1992:39-55.
On firstname terms
Not long after I retired I ran into one ofour old students as
I was leaving a medical meeting. We exchanged the usual
civilities and then he said, "There was one thing you
taught me on a ward round which I have never forgotten."
I was flattered but mystified. "What was that?" "You
asked me to examine an old man in one of the medical
beds, and I said to him 'Sit up Dad, let's have a look at
you.' You pulled me up instantly. 'He is not your Dad he
isMrJones and that is howyou should speak to him."'
My role has changed-from doctor to patient. I returned
recently to my old hospital for a small operation. I have
nothing but praise for the way that I was treated by all
concerned. Only one small incident made me feel a little
uncomfortable. A young male nurse ushered me into an
office with a cheerful "Come in Arthur, I just want to do a
few tests." A trifle, but somehow it grated. I come of a
generation when the surname was the usual form of
address, except among close friends and relatives. As a
youth a nickname was sometimes bestowed on me. Later
I learnt to be on first name terms with colleagues.
Nowadays, ofcourse, the first name address is so common
that people are unable to tell you the surnames of any of
their friends. I was pernickety and out of date. Narrowing
of cerebral arteries and diminishing cerebral neurones
must be my excuse.
But at the eleventh hour Katharine Whitehorn, with
her usual humanity and commonsense, has come to
the rescue (The Observer, 9 April 1995). Medics, she
maintains, "lead the field in the intrusive intimacy of
calling everybody by their
addresses you as Jane because he thinks he is being
friendly, and his receptionists and bottle washers follow
suit." She adds that "calling someone by their first name
who must still call you Doctor, Nurse or Sir simply
emphasises your superiority."
We mean well, but nothing is straightforward. How
difficult it all is. I do not really mind being called Arthur,
now that I have got used to it. It is better than being called
Dad by a total stranger.-A L WYMAN is a retired consultant
physician in London
first names. The doctor
1 JULY 1995