Qualitative research is an umbrella term describing a multitude of systematic interpretive methods that aim to understand the subjective human experience and its relation to the myriad of social and cultural factors that contribute to our constructed realities1. Qualitative methods have therefore proved invaluable in health services research and practice, allowing researchers, policymakers and practitioners to not only better understand the theoretical meaning of health2 but also how people experience a service, why an evidence-based intervention does not work in real life3 (which has since become implementation science) or how practitioners think and act4. The interpretive paradigm has helped shed light on complex dynamic relationships between health, culture, society and the healthcare system5; impossible with numbers alone, but essential to studying and improving social and personal well-being.

Since its introduction to health and health policy, the interpretive approach has led to tangible change, generating actionable insights. For example, in the late 1990s, there was concern in the UK over rapidly increasing deaths from paracetamol overdose6. Qualitative interviews revealed that the behaviour was largely impulsive7. This crucial piece of evidence subsequently lead to policy change and a pack-limit with a resultant sharp and sustained decrease in paracetamol related deaths8. Indeed, while quantitative measures give indications of alarming trends9 and health implications, they explain little of the underlying processes, failing to answer essential questions required to tackle such issues.

In recognition of its value, recent health and social policy have required increasing commitment to engage with the voices and perspectives of everyone involved in the healthcare system10, something that can only be achieved with a qualitative line of inquiry. Furthermore, the interpretive approach is analogous with the wider movement to patient-centred care and the biopsychosocial model of illness, stressing the importance of considering people and their unique complexities in how health is provisioned11, conceptualised12, and practiced13. Even the highest level of UK government has recognised its value by commissioning a guide on appraising such evidence for its use in policies14. Simultaneously, qualitative methods also evolved with synthesised systematic reviews emerging similar in nature and purpose to their quantitative counterparts5.

In my opinion, despite seemingly wide-spread adoption, qualitative research appears to still be undervalued and thus subsequently underused. Empirical studies continue to demonstrate how stakeholders often favour quantitative statistics when asked for evidence15, while qualitative studies continue to be side-lined by popular method agnostic clinical journals16, despite high citations and demonstratable impact. Perhaps the issue may lie with an understanding of historical events and the development of evidence-based practice (EBP) itself.

Prompted by increasing clinical complexity, rising costs, increasing social and cultural diversity, growing demands and even scarcer resources17, decisions regarding health and society were to be justified with seemingly objective evidence18 (EBP). Ascending from the post-renaissance movement, traditional or quantitative methods dominated and were upheld as the pinnacle of such evidence, seeking to identify universal truths (generalisability). Evidence within this paradigm implied measurable empirical observations which could be summarised and presented with statistics19. Quantitative researchers criticised the interpretive approach as having far too small sample sizes to be generalisable, findings biased by the researcher’s opinion or experience, while not objective20. The promotion of the “hierarchy of evidence” (case studies confined to the lowest rung) further contributed to the enduring scepticism in the validity of the qualitative line of inquiry21, while others likened it to “…the exploitation of rationality at the expense of humanity”22. Quantitative data remains crucial, despite growing concern that the “one-size-fits-all” approach is too reductionist18, impersonal, and not reflective of real lived experiences23, the hidden assumptions and inherent biases of the quantified positivist movement continue to permeate in the minds of some researchers and practitioners today1.

Indeed, while qualitative methodologies may at first appear dichotomous to their quantitative counterparts, their respective values lie in the weaknesses of the other24. Neither is more valuable, with both required to understand any phenomenon. Despite progress in the form of recent international acknowledgement by the World Health Organisation25, acceptance by the International Cochrane Collaboration26 and release of GRADECERQual (‘Confidence in the Evidence from Reviews of Qualitative research’)27, qualitative research continues to be neglected by some and perhaps misunderstood by others, who are involved in the development of health policies and guidelines. Moving beyond scholarly debates, as guardians of health, we owe it to society to ensure we do not artificially limit our toolbox in our quest for continual advancement, finding a balance between the objectivity of numbers and the subjectivity and sanctity of the human experience, each with its rightful place.

  1. Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. An introduction to implementation science for the non-specialist. BMC Psychol. 2015;3(1):32. doi:10.1186/s40359-015-0089-9
  2. Alexander L, Allen S, Bindoff NL. Summary for Policymakers. Vol 53.; 2013. doi:10.1017/CBO9781107415324.004
  3. Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res. 2017;19(11):e367. doi:10.2196/jmir.8775
  4. Platt D, Muller I, Sufraz A, Little P, Santer M. GPs’ perspectives on acne management in primary care: a qualitative interview study. Br J Gen Pract. 2020;71(702):bjgp20X713873. doi:10.3399/bjgp20x713873
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  7. Hawton K, Ware C, Mistry H, et al. Paracetamol self-poisoning: Characteristics, prevention and harm reduction. Br J Psychiatry. 1996;168(JAN.):43-48. doi:10.1192/bjp.168.1.43
  8. Gunnell D, Hawton K, Ho D, et al. Hospital admissions for self harm after discharge from psychiatric inpatient care: Cohort study. BMJ. 2008;337(7682):1331-1334. doi:10.1136/bmj.a2278
  9. Wasserman D, Cheng Q, Jiang G-X. Global suicide rates among young people aged 15-19. World Psychiatry. 2005;4(2):114-120. Accessed January 9, 2021. http://www.ncbi.nlm.nih.gov/pubmed/16633527
  10. NHS England » Involving people in health and care guidance. Accessed January 8, 2021. https://www.england.nhs.uk/participation/involvementguidance/
  11. Oshima Lee E, Emanuel EJ. Shared Decision Making to Improve Care and Reduce Costs. N Engl J Med. 2013;368(1):6-8. doi:10.1056/nejmp1209500
  12. Bolton D, Gillett G, Bolton D, Gillett G. Biopsychosocial Conditions of Health and Disease. In: The Biopsychosocial Model of Health and Disease. Springer International Publishing; 2019:109-145. doi:10.1007/978-3-030-11899-0_4
  13. Kusnanto H, Agustian D, Hilmanto D. Biopsychosocial model of illnesses in primary care: A hermeneutic literature review. J Fam Med Prim Care. 2018;7(3):497. doi:10.4103/jfmpc.jfmpc_145_17
  14. Spencer L, Ritchie J, Lewis J, Dillon L. Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence – GOV.UK. Accessed January 8, 2021. https://www.gov.uk/government/publications/government-social-research-framework-for-assessing-research-evidence
  15. Sallee MW, Flood JT. Using Qualitative Research to Bridge Research, Policy, and Practice. Theory Pract. 2012;51(2):137-144. doi:10.1080/00405841.2012.662873
  16. Greenhalgh T, Annandale E, Ashcroft R, et al. An open letter to the BMJ editors on qualitative research. BMJ. 2016;352(February):1-4. doi:10.1136/bmj.i563
  17. Johnson MO. The shifting landscape of health care: Toward a model of health care empowerment. Am J Public Health. 2011;101(2):265-270. doi:10.2105/AJPH.2009.189829
  18. Olson K, Young RA. Handbook of Qualitative Health Research for Evidence-Based Practice. Vol 4.; 2016. doi:10.1007/978-1-4939-2920-7
  19. Green J, Thorogood N. Qualitative Methods for Health Research. Sage; 2004.
  20. Pearce LD. Thinking Outside the Q Boxes: Further Motivating a Mixed Research Perspective. Oxford Handb Multimethod Mix Methods Res Inq. Published online 2015:42-56. doi:10.1017/CBO9781107415324.004
  21. Guyatt GH, Naylor D, Richardson WS, et al. What is the best evidence for making clinical decisions? JAMA. 2000;284(24):3127-3128.
  22. Heath I. How medicine has exploited rationality at the expense of humanity: An essay by Iona Heath. BMJ. 2016;355. doi:10.1136/bmj.i5705
  23. Faltermaier T. Why public health research needs qualitative approaches: Subjects and methods in change. Eur J Public Health. 1997;7(4):357-363. doi:10.1093/eurpub/7.4.357
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