Qualitative research comes of age

For a long, long time, qualitative research has felt like a "poor relation" to quantitative: so much more subjective, so much harder to generalise, so much more reliant on the skills of the researcher to deliver quality.

I'm delighted to see that it's becoming more mainstream - at least based on the evidence of a couple of recent publications that appear in the mainstream research literature and that simply report on how to report qualitative research well. One is in the medical literature, and the other in the psychology literature. The questions of what constitutes high quality qualitative research, and how to report it are ones we have grappled with, particularly when the findings of a study don't align well with the original aims because you discover that those aims were based on incorrect assumptions about the situation. I still get the sense that there is asymmetry in the situation: that qualitative researchers have to justify their methods to quantitative researchers much more forcefully than the converse. But this seems like progress nevertheless.

Quantitative tells you about outcomes, but gives little (or no) insight into causes or processes. To improve outcomes, you really need to understand causes too...

On rigour, numbers and discovery

Recently, I was asked the following:

In talking to my psychology seminar group about their qualitative lab I ended up looking at Helene Joffe’s book chapter on thematic analysis.  She suggests including diagrammatic representations of the themes, together with quantitative data about how many participants mentioned the theme, and it’s subparts.  This appealed to the psychology students because it gives them quantitative data and helped them see how prevalent that theme was within the sample.

And then today I saw another paper “Supporting thinking on sample sizes for thematic analyses: a quantitative tool".  It argues that one should consider the power of the study when deciding on sample size – another concept I’d only seen in quantitative research. 

Both of these sources seem to be conducting qualitative analysis with at least a nod towards some of the benefits of quantitative data, which appears to make qualitative analysis have more rigor.  Of course, simply adding numbers doesn’t necessarily make something more rigorous but it does add more information to results of an analysis and this could influence the reader’s perception of the quality of the research.  However, I don’t recall seeing this is any HCI papers.  Why isn’t it used more often? 

The answer (or at least, my answer) hinges on nuances of research tradition that are not often discussed explicitly, at least in HCI:

Joffe, Fugard and Potts are all thinking and working in a positivist tradition that assumes an independent reality ‘out there’, that doesn’t take into account the role of the individual researcher in making sense of the data. Numbers are great when they are meaningful, but they can hide a lot of important complexity. For example in our study of people’s experience of home haemodialysis, we could report how many of the participants had a carer and how many had a helper. That’s a couple of numbers. But the really interesting understanding comes in how those people (whether trained as a carer or just acting as a helper) work with the patient to manage home haemodialysis, and how that impacts on their sense of being in control, how they stay safe, their experience of being on dialysis, and the implications for the design of both the technology and the broader system of care. Similarly, we could report how many of their participants reported feeling scared in the first weeks of dialysis, but that didn’t get at why they felt scared or how they got through that stage. We could now run a different kind of study to tease out the factors that contribute to people being scared (having established the phenomenon) and put numbers on them, but to get the larger (60-80) participants needed for this kind of analysis would involve scouring the entire country for willing HHD participants and getting permission to conduct the study from every NHS Trust separately; I’d say that’s a very high cost for a low return.

Numbers don’t give you explanatory power and they don’t give you insights into the design of future technology. You need an exploratory study to identify issues; then a quantitative analysis can give the scale of the problem, but it doesn’t give you insight into how to solve the problem. For HCI studies, most people are more interested in understanding the problem for design than in doing the basic science that’s closer to hypothesis testing. Neither is right or wrong, but they have different motivations and philosophical bases. And as Gray and Salzman argued, many years ago, using numbers to compare features that are not strictly comparable – in their case, features of different usability methods when used in practice – is 'damaged' (and potentially damaging).

Wolcott (p.36) quotes a biologist, Paul Weiss, as claiming, “Nobody who followed the scientific method ever discovered anything interesting.” The quantitative approach to thematic analysis doesn’t allow me to answer many of the questions I find interesting, so I’m not going to shift in that direction just to do studies that others consider more rigorous. Understanding the prevalence of phenomena is important, but so is understanding the phenomena, and the techniques you need for understanding aren’t always compatible with those you need for measuring prevalence. Unfortunately!

Compliance, adherence, and quality of life

My father-in-law used to refuse presents on the principle that all he wanted was a "bucket full of good health". And that was something that no one is really in a position to give. Fortunately for him (and us!) he remained pretty healthy and active until his last few weeks. And this is true for many of us: that we have mercifully little experience of chronic ill health. But not everyone is so lucky.

My team has been privileged to work with people suffering from chronic kidney disease, and with their families, to better understand their experiences and their needs when managing their own care. Some people with serious kidney disease have a kidney transplant. Others have dialysis (which involves having the blood 'cleansed' every couple of days). There is widespread agreement amongst clinicians that it's best for people if they can do this at home. And the people we worked with (who are all successful users of dialysis technology at home) clearly agreed. They were less concerned, certainly in the way they talked with us, about their life expectancy than about the quality of their lives: their ability to go out (for meals, on holiday, etc.), to work, to be with their families, to feel well. Sometimes, that demanded compromise: some people reported adopting short-cuts, mainly to reduce the time that dialysis takes. And one had her dialysis machine set up on her verandah, so that she could dialyse in a pleasant place. Quality of life matters too.

The health literature often talks about "compliance" or "adherence", particularly in relation to people taking medication. There's the same concern with dialysis: that people should be dialysing according to an agreed schedule. And mostly, that seemed to be what people were doing. But sometimes they didn't because other values dominated. And sometimes they didn't because the technology didn't work as intended and they had to find ways to get things going again. Many of them had turned troubleshooting into an art! As more and more health management happens at home, which means that people are immediately and directly responsible for their own welfare, it seems likely that terms like "compliance" and "adherence" need to be re-thought to allow us all to talk about living as enjoyably and well as we can – with the conditions we have and the available means for managing those conditions. And (of course) the technology should be as easy to use and safe as possible. Our study is hopefully of interest: not just to those directly affected by kidney disease or caring or designing technology for managing it, but also for those thinking more broadly about policy on home care and how responsibility is shared between clinicians, patients and family.

Strategies for doing fieldwork for health technology design

The cartoons in this blog post are  from Fieldwork for Healthcare: Guidance for Investigating Human Factors in Computing Systems.  © 2015 Morgan and Claypool Publishers, www.morganclaypool.com. Used with permission.

One of the themes within CHI+MED has been better understanding how interactive medical devices are used in practice, recognising that there are often important differences between work as imagined and work as done.  This has meant working with many people directly involved in healthcare (clinicians, patients, relatives) to understand their work when interacting with medical devices: observing their interactions and interviewing them about their experiences. But doing fieldwork in hospitals and in people’s homes is challenging:

• You need to get formal ethical clearance to conduct any study involving clinicians or patients. As I’ve noted previously, this can be time-consuming and frustrating. It also means that it can be difficult to change the study design once you discover that things aren’t quite the way you’d imagined, however much preparatory work you’d tried to do. 
• Hospitals are populated by people from all walks of life, old and young, from many cultures and often in very vulnerable situations. They, their privacy and their confidentiality need to be respected at all times.
• Staff are working under high pressure. Their work is part-planned, part-reactive, and the environment is complex: organisationally, physically, and professionally. The work is safety-critical, and there is a widespread culture of accountability and blame that can make people wary of being observed by outsiders.
• Health is a caring profession and, for the vast majority of staff, technology use is a means to an end; the design of that technology is not of interest (beyond being a source of frustration in their work).
• You’re always an ‘outsider’: not staff, not patient, not visitor, and that’s a role that it can be difficult to make sense of (both for yourself and for the people you’re working with).
• Given the safety-critical nature of most technologies in healthcare, you can’t just prototype and test ‘in the wild’, so it can be difficult to work out how to improve practices through design.

When CHI+MED started, we couldn’t find many useful resources to guide us in designing and conducting studies, so we found ourselves ‘learning on the job’. And through discussions with others we realised that we were not alone: that other researchers had very similar experiences to ours, and that we could learn a lot from each other.

So we pooled expertise to develop resources to give future researchers a ‘leg up’ for planning and conducting studies. And we hope that the results are useful resources for future researchers:

• We’ve recently published a journal paper that focuses on themes of gaining access; developing good relations with clinicians and patients; being outsiders in healthcare settings; and managing the cultural divide between technology human factors and clinical practice.
• We’ve published two books on doing fieldwork in healthcare. The first volume reported the experiences of researchers through 12 case studies, covering experiences in hospitals and in people’s homes, in both developed and developing countries. The second volume presents guidance and advice on doing fieldwork in healthcare. The chapters cover ethical issues, preparing for the context and networking, developing a data collection plan, implementing a technology or practice, and thinking about impact.
• Most of our work is neither pure ethnography nor pure Grounded Theory, but somewhere between the two in terms of both data gathering and analysis techniques: semi-structured, interpretivist, pragmatic. There isn’t an agreed name for this, but we’re calling them semi-structuredqualitative studies, and have written about them in these terms.

If you know of other useful resources, do please let us know!

Let's be pragmatic: one approach to qualitative data analysis

Today, Hanna, one of my MSc students, has been asking interesting questions about doing a qualitative data analysis. Not the theory (there's plenty about that), but the basic practicalities.

I often point people at the Braun & Clarke (2006) paper on thematic analysis: it’s certainly a very good place to start. The Charmaz book on Grounded Theory (GT) is also a great resource about coding and analysis, even if you’re not doing a full GT. And I've written about Semi-Structured Qualitative Studies. For smallish projects (e.g. up to 20 hours of transcripts), computer-based tools such as  Atlas ti, nVivo and Dodoose tend to force the analyst to focus on the tool and on details rather than on themes.

I personally like improvised tools such as coloured pens and lots of notebooks, and/or simple Word files where I can do a first pass of approximate coding (either using the annotation feature or simply in a multi-column table). At that stage, I don’t worry about consistency of codes: I’m just trying to see what’s in the data: what seem to be the common patterns and themes, what are the surprises that might be worth looking at in more detail.

I then do a second pass through all the data looking systematically for the themes that seem most interesting / promising for analysis. At this stage, I usually copy-and-paste relevant chunks of text into a separate document organised according to the themes, without worrying about connections between the themes (just annotating each chunk with which participant it came from so that I don’t completely lose the context for each quotation).

Step 3 is to build a narrative within each of the themes; at this point, I will often realise that there’s other data that also relates to the theme that I hadn’t noticed on the previous passes, so the themes and the narrative get adapted. This requires looking through the data repeatedly, to spot omissions. While doing this, it's really important to look for contradictory evidence, which is generally an indication that the story isn't right: that there are nuances that haven't been captured. Such contradictions force a review of the themes. They may also highlight a need to gather more data to resolve ambiguities.

The fourth step is to develop a meta-narrative that links the themes together into an overall story. At this point, some themes will get ditched; maybe I’ll realise that there’s another theme in the data that should be part of this bigger narrative, so I go back to stage 2, or even stage 1.  Repeat until done!

At some point, you relate the themes to the literature. In some cases, the literature review (or a theory) will have guided all the data gathering and analysis. In other cases, you get to stage 4, realise that someone has already written exactly that paper, utter a few expletives, and review what alternative narratives there might be in your data that are equally well founded but more novel. Usually, it’s somewhere between these extremes.

This sounds ad-hoc, but done properly it’s both exploratory and systematic, and doesn’t have to be constrained by the features of a particular tool.

Hidden in full view: the daft things you overlook when designing and conducting studies

Several years ago, when Anne Adams and I were studying how people engaged with health information, we came up with the notion of an "information journey", with three main stages: recognising an information need; gathering information and interpreting that information. The important point (to us) in that work was highlighting the important of interpretation: the dominant view of information seeking at that time was that if people could find information then that was job done. But we found that an important role for clinicians is in helping lay people to interpret clinical information in terms of what it means for that individual – hence our focus on interpretation.

In later studies of lawyers' information work, Simon Attfield  and I realised that there were two important elements missing from the information journey as we'd formulated it: information validation and information use. When we looked back at the health data, we didn't see a lot of evidence of validation (it might have been there, but it was largely implicit, and rolled up with interpretation) but – now sensitised to it – we found lots of evidence of information use. Doh! Of course people use the information – e.g. in subsequent health management – but we simply hadn't noticed it because people didn't talk explicitly about it as "using" the information. Extend the model.

Wind forwards to today, and I'm writing a chapter for InteractionDesign.org on semi-structured qualitative studies. Don't hold your breath on this appearing: it's taking longer than I'd expected.

I've (partly) structured it according to the PRETAR framework for planning and conducting studies:

• what's the Purpose of the study?
• what Resources are available?
• what Ethical considerations need to be taken into account?
• what Techniques for data gathering?
• how to Analyse data?
• how to Report results?

...and, having been working with that framework for several years now, I have just realised that there's an important element missing, somewhere between resources and techniques for data gathering. What's missing is the step of taking the resources (which define what is possible) and using them to shape the detailed design of the study – e.g., in terms of interventions.

I've tended to lump the details of participant recruitment in with Resources (even though it's really part of the detailed study design), and of informed consent in with Ethics. But what about interventions such as giving people specific tasks to do for a think-aloud study? Or giving people a new device to use? Or planning the details of a semi-structured interview script? Just because a resource is available, that doesn't mean it's automatically going to be used in the study, and all those decisions – which of course get made in designing a study – precede data gathering. I don't think this means a total re-write of the chapter, but a certain amount of cutting and pasting is about to happen ...

When I get older: the uncountable positives

Last week, I was at a presentation by John Clarkson. It was a great talk: interesting, informative, thought provoking… Part-way through it, to make a point about the need for accessible technology, he presented a set of graphs showing how human capabilities decline with age. Basically, vision, hearing, strength, dexterity, etc. peak, on average, in the 20s, and it’s downhill all the way from there. It is possible that only two measurable values increase with age: age itself and grumpiness!

So this raises the obvious question: if we peak on every important variable when we’re in our 20s, why on earth aren’t most senior roles (Chief Executive, President, etc.) held by people in their 20s? Is this because grumpiness is in fact the most important quality, or is it because older people have other qualities that make them better suited to these roles? Most people would agree that it’s the latter.

The requisite qualities are often lumped under the term “wisdom”. I’m not an expert on wisdom, but I imagine there’s a literature defining and decomposing this concept to better understand it. One thing’s for sure though: it can’t be quantified in the way that visual or auditory acuity, strength, etc. can. The things that matter most for senior roles are not easily quantified.

We run a risk, in all walks of life, of thinking that if it can’t be measured then it has no value. In research we see it repeatedly in the view that the “gold standard” for research is controlled (quantifiable) experiments, and that qualitative research is “just stories”. In healthcare, this thinking manifests itself in many ways: in measures of clinical effectiveness and other outcome measures. In HCI, it manifests itself in the weight put on efficiency: of course, efficiency has its place (and we probably all have many examples of inefficient, frustrating interfaces), but there are many cases where the less easily measured outcomes (the quality of a search, the engagement of a game) are much more important.

As vision, hearing, memory, etc. decline, I'm celebrating wisdom and valuing the unmeasurable. Even if it can sound like "just stories'.