What are the difference between some aspects of Qualitative Research and Patient/Public Involvement?
NB: If you can come to read about Knickers to Involvement, you will have to read the whole post ;-)
I struggle to describe and define the difference when asked this question at a workshop. I fall back on the easy response of referring people to the joint HRA/Involve paper. Putting my thoughts done here was initially prompted by a conversation with Kristina Staley and Bec Hanley. We just met for a chat over coffee and that conversation set us all thinking and these ramblings.
PLEASE READ Kristina's Blog where we are trying to set out our thinking in a chart.
Please use #QualitativeandPPI when responding on Twitter
As for my thoughts….
I suspect that it is an exercise in how little I actually know but I always find that seeing the printed word helps to clarify my thoughts. It allows me to hopefully apply some logic to unpick the issues. As with virtually all I write, it is an attempt to enquire - the purposeful use of a question in a search for sense.
At the outset, I should indicate my commitment to Qualitative Research is almost unbounded. I consider that it provides valuable evidence about people's opinions, attitudes and experiences of healthcare. I believe that all clinical trials that have a qualitative element have a greater potential to provide a broader understanding to help make better clinical decisions. I am therefore, I suppose, biased.
The practices of both Qualitative Research and Patient Involvement have their own place in developing of improving people’s health and wellbeing. I would like to suggest that for the most part they are fundamentally different, yet at other moments they are almost joined seamlessly. They may even at times occasionally collide.
Let me start by seeking to illustrate what I believe to be the difference.
Sharpening the Research Question
A researcher may set a question based on validated qualitative evidence that requires further enquiry. It may be seen by the clinical and academic community to be the valid question to ask and therefore worthy of enquiry. Peer review may support the hypothesis that subsequently leads to a successful funding application.
Patient Involvement, however, can often give a more nuanced view about the research question. It is about how the question is phrased, the subtleties of tone in certain words.
I have heard researchers say that by involving patients and the public that their question became much better. The changes proposed by actively involving patients and the public have been about making the questions sharper, more pertinent and precise to the needs of those who are the intended beneficiaries of the study. These discussions are rarely about changing the actual question or telling the researchers what to study yet some researchers see this as a genuine concern.
Patient involvement is firmly in the area of the ‘personal’ - the distinctive added value, driven by direct experiences. Qualitative Research seems to provide a synthesis of opinion.
But where does Patient Involvement come together with Qualitative Research?
The Unanswered Questions
These partnerships gather the separate views of patients and researchers. This joint nature of this endeavour makes it then difficult to see exactly where the line between the two falls. I am not sure this matters as it is the outcome of identifying the areas that need further research that are most important.
Let me offer another example focusing on a particular practical task...
Personalising the Patient Information Leaflet
We, patients and researchers equally, want Patient Information Leaflets that provide accurate and helpful advice about a study.
Qualitative research can provide useful evidence about what makes a good Patient Information Leaflet. It can ask for people’s views about how they might like to receive information. These studies can provide useful advice about content, layout and format. Yet, this qualitative research is often general advice and less study specific.
Patient Involvement can give advice that is about the individual study. It can suggest the use of different words, changes in tone, alter the layout to make better sense. It is about the ‘personal touch’ from people who experience and know about the condition/illness being researched.
There is a strange dichotomy here that I, as a patient advocate, know about the work on Patient Information Leaflets, yet many researchers I work with don’t. Qualitative research can therefore inform and influence patient involvement and the latter‘s knowledge can inform about the value of this work.
Peter Knapp, a senior lecturer at York, states that there is no evidence about whether this leads to more people taking part in studies yet it feels morally right and reassuring that patients have had a say in the development of the research.
This personal perspective and moral compass can be replicated in adding value to inclusion criteria, recruitment, analysing data and in the way research is disseminated.
But, how else might we work together yet retain our separate perspectives?
Patient as Partners in Qualitative Research
I had the pleasure of attending a workshop in Nottingham where a researcher wanted to ensure that the work identified areas of genuine importance to patients, which researchers might miss when running focus groups.
She and colleagues ran a half-day introductory workshop on the qualitative method they were using which everyone found highly informative, enjoyable and useful. One of the patient reps then sat in on the focus group, which was seen to draw out a deeper understanding of patients real concerns.
The qualitative researchers are still qualitative researchers giving that professional viewpoint. The patient partner is still giving the patient perspective and able to identify a phrase or attitude that reveals a truth. By working together they each add value.
Words have Different Meaning
I have heard and read much about the attitudes of people affected by cancer to the word ‘battle’ being used in articles and conversations with patients. It seems sensible therefore to avoid using a word in a leaflet that might upset or even offend someone but how will we know without having those conversations.
You may also have noticed that I just used the phrase ‘people affected by cancer’ rather than patients. I use it because it is more inclusive of relatives, friends and colleagues. I was a cancer patient almost quarter of a century ago - I am not now. It is these subtle changes that sit within all health domains, are prevalent across all professions and exist in all relationships.
Involving patients and the public is that opportunity for a reality check. It is on the grounding in real life understanding. It is the application of common sense. Paul Workman, from the Institute for Cancer Research wrote about this recently.
A Summary
Qualitative research is rightly about standing back, observing, gathering and analysing the evidence to offer comment. Patient Involvement is more about stepping forward to speak up from a personal perspective. Meeting each other and working together for mutual understanding and making research personal. It is about mutual gain from a relationship.
Qualitative Research is clearly about ‘evidence’ whilst Patient Involvement may be more about the ‘individual’ but each brings and provides knowledge. It seems to me that it is as incumbent on patient advocates to know about qualitative research as it so often relies on their experiences and provides backing for our discussions. It is a chance to learn about the different methodologies that are used from questionnaires and surveys to narrative analysis.
We can understand why people take part in but it was many patients who asked for a Patient Research Experience Survey about what taking part is actually like. We will want and need qualitative research to review, analyse and give evidence about the types of questions, the responses achieved. But sometimes it is about the poster on the wall, a mis-worded phrase that lacks the personal sensitivity and empathy.
And finally
A person may choose to buy and wear clothes to make them feel that they are reasonably keeping up with fashion but the views of their close family and friends can give opinions that are both immediately practical and apposite. They may be kind or maybe difficult to hear yet they stop us looking ridiculous.
There is a part of Patient/Public Involvement that can say the Emperor has no clothes when those working in research may be more conscious about their careers.
There was a wonderful quote on Twitter recently that Involving Patients and the Public "might reduce the chance of the researcher making an arse of themselves".
If that is correct, then I wonder then if Qualitative Research may be more about saying what type of knickers we prefer to wear. But is it Patient Involvement that can really say which knickers are the most comfortable?
PLEASE READ Kristina's Blog where we are trying to set out our thinking in a chart.
Please use #QualitativeandPPI when responding on Twitter
