Editorial |
Qualitative research and Occupational Medicine
1 Occupational Health Service, Durham County Council, UK
2 The Health and Occupation Reporting Network (THOR), Occupational and Environmental Health Research Group, University of Manchester, Manchester, UK
e-mail: philip.wynn{at}durham.gov.uk
Occupational medicine research has a long and distinguished history of observational studies establishing the epidemiology of work-related disorders [1]. More recent developments in evidence-based medicine have led to the publication of increasing numbers of experimental studies determining the effectiveness of workplace-based health interventions. These approaches have had notable success in reducing the burden of the traditional work-related disorders. However, the late 20th century saw, in all branches of medicine, an increasing proportion of disorders with no recognizable pathological or organic cause. These disorders have been estimated to account for 70% of all attendances in outpatient services and 90% of all general practitioner visits [2]. The burden of work-related disorders has also shifted towards disorders not amenable to objective measurement, such as psychological disorders and the many chronic pain syndromes. Of equal concern is the limited ‘effectiveness’ of good evidence-based interventions, such as for chronic simple low back pain, in the ‘real-life’ situation of day-to-day occupational health practice where a significant minority of employees do not return to work even after the relevant evidence-based interventions are applied. Classical experimental and observational research methodologies have, in the case of back pain, identified factors that may influence the decision to return to work but, to date, these experimental approaches have not offered the same degree of insight into the effective workplace management of the major contemporary contributors to disability and morbidity in working age adults, compared to the work-related disorders of earlier industrial periods.
Reasonable questions for academic occupational health to ask, to address these discrepancies, include the following: Are there factors related to the way advice is provided to employees by occupational health professionals that reduces its effectiveness? What cognitive process does the employee go through to decide work would be detrimental to health? Equally, surveys of working adults utilizing the General Health Questionnaire frequently find ‘caseness’ levels for psychiatric disorders in up to 15% of adults attending work [3]. Consequently, the overwhelming majority of working adults with the common psychiatric disorders are at work and not on sickness absence. What factors influence the worker with a common health disorder to withdraw from work? Although quantitative studies have contributed to our knowledge in this area, the research has provided only limited insight into the belief systems and psychological factors of individual employees making them most at risk of adverse effects from work-related stressors, subsequent absence and chronic disability.
Qualitative research may offer insight into these major issues for occupational health. The general consensus is that qualitative research is an interpretative approach concerned with understanding the meanings that people attach to their actions, beliefs, values and so on, and an approach that focuses and attempts to understand the ways in which people make sense of and interpret the world around them. Kuper has highlighted a tendency, particularly within the health sciences, to conceptualize qualitative research as just one type of methodology. In fact, several methodologies are involved with differing tools including observation, participant observation, in-depth interviews, focus groups, life histories and conversation analysis which researchers can employ depending on the kind of research question that is being explored [4].
Discussions of what qualitative research is will almost always tend to posit it in direct opposition to quantitative research methods. So, quantitative researchers are concerned with the measurement of causality between variables and with numerical and statistical inference and generalizability from large samples; whereas qualitative researchers hold the belief that there is no single reality that can be easily observed and that the best way to understand any phenomenon is to view it in its context; quantification is, by its very nature, limiting. Different epistemological and ontological assumptions inform qualitative and quantitative research methodologies. Quantitative research is associated with a deductive approach to scientific enquiry, whereas qualitative research employs inductive reasoning. Simplifying to the extreme, this means quantitative research is associated with the notion of science as fact, with quantitative researchers setting out to test existing theories by providing data that support or disprove pre-conceived hypotheses. Qualitative research, on the other hand, commences with more open-ended observations about a particular area of interest, the collection of data and emerging patterns, and then the generation of ideas or ‘hypotheses’ from which conclusions and theories can be made. In this respect, qualitative research answers the ‘how’ and ‘why’ rather than the ‘how often’ questions. Table 1 summarizes the main distinctions often made in the theoretical debate surrounding qualitative and quantitative research methodologies.
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One of the difficulties that qualitative research has in being fully accepted into the health sciences field as a legitimate methodology is due to the commonly held view that it is intrinsically ‘unscientific’ [6]. This commonly held view is based on the assertions that qualitative research methods lack rigour, reproducibility and generalizability; are anecdotal in nature and are usually undertaken with samples too small for statistical analysis [7]. Underlying this assumption is the idea that quantitative methods are reliable but not valid, and qualitative methods are valid but not reliable; however, this distinction is not as clear as this would suggest [8].
The importance of self-reported disorders and the impact of individual patient beliefs and psychology on the effectiveness of the outcome of health services for patients with well-recognized pathology, such as diabetes and epilepsy, are well accepted within the mainstream UK medical research establishment. For more than 10 years in the UK, the British Medical Journal and British Journal of General Practice have promoted and published research adopting a qualitative methodology. These have sought to explore, usually by semi-structured interview, the beliefs and attitudes of patients and doctors that may help explain differing health-seeking behaviours by patients and referral rates by doctors. Such approaches include the exploration of differentials in care-seeking behaviour by patients with angina from more socially deprived backgrounds [9], beliefs acting as barriers to engagement with pulmonary rehabilitation in patients with chronic obstructive pulmonary disease [10], compliance in type 2 diabetes in minority communities [11] and doctor-related factors in antibiotic prescribing rates [12].
The editorial team of Occupational Medicine believes there is value in introducing a mix of qualitative with quantitative research to the journal. Quantitative research excels at summarizing large amounts of data and reaching generalizations; qualitative research we believe excels at telling the story from the participants’ point of view, providing rich detail that sets results into their human context. As a journal, we seek to encourage submission of high-quality quantitative research. We encourage researchers in the occupational health field, and undertaking qualitative research, to consider Occupational Medicine as a route to the dissemination of their work.
References
- McDonald C. Occupational epidemiology. In: Epidemiology of Work-Related Disorders—McDonald C, ed. (2000) 2nd edn. London: BMJ Books.
- Halligan P, Aylward M, eds. The Power of Belief: Psychological Influence on Illness, Disability, and Medicine (2006) Oxford: OUP.
- Ferrie JE, Shipley M, Davey S, Stansfeld S, Marmot M. Change in health inequalities among British Civil Servants: the Whitehall II study. J Epidemiol Community Health (2002) 56:922–926.
[Abstract/Free Full Text] - Kuper A, Reeves S, Levinson W. An introduction to reading and appraising qualitative research. Br Med J (2008) 337:288.[CrossRef]
- Casebeer A, Verhoef M. Combining qualitative and quantitative research methods: considering the possibilities for enhancing the study of chronic diseases. Chronic Dis Can (1997) 18. http://phac-aspc.gc.ca/publicat/cdic-mcc/18-3/d_e.html (24 November 2008, date last accessed).
- Pope C, Mays N. Qualitative research: reaching the parts other methods cannot reach: an introduction to methods in health and health services research. Br Med J (1995) 311:42–45.
[Free Full Text] - Black N. Why we need qualitative research. J Epidemiol Commun Health (1994) 48:425–426.
[Free Full Text] - Britten N, Fisher B. Qualitative research and general practice. Br J Gen Pract (1993) 372:270–271.
- Gardner K, Chapple A. Barriers to referral in patients with angina: qualitative study. Br Med J (1999) 319:418–421.
[Abstract/Free Full Text] - Harris D, Hayter M, Allender S. Improving the uptake of pulmonary rehabilitation in patients with COPD—qualitative experiences and attitudes. Br J Gen Pract (2008) 58:703–710.[CrossRef][Web of Science][Medline]
- Lawton J, Ahmad N, Hallowell N, Hanna L, Douglas M. Perceptions and experiences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: qualitative study. Br Med J (2005) 330:1247.
[Abstract/Free Full Text] - De Souza V, MacFarlane A, Murphy AW, Hanahoe B, Barber A, Cormican M. A qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors. J Antimicrob Chemother (2006) 58:840–843.
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