卫生服务研究中的定性研究方法

传统的卫生服务研究方法以定量研究方法 (quantitativere searchmethods )为主。描述性研究、分析性研究、试验研究以及理论研究等方法都主要采用定量的方法收集、分析资料。近 10年来 ,定性研究方法 (qualitativeresearchmethods )在我国越来越多地被应用于卫生服务研究领域。定性研究是研究社会现象的一种广泛采用的方法和手段 ,收集的资料形式通常是文字、声音、图像等 ,而不是数字形式。本系列文章将介绍几种在卫生服务研究中常用的定性研究方法。作为系列文章的第一篇 ,本文将介绍定性研究方法的特点、定性研究与定量研究方法的关系、…     

Qualitative research methods.

The use of rigorous qualitative research methods can enhance the development of quality measures, the development and dissemination of comparative quality reports, as well as quality improvement efforts. This paper describes how such methods have been and can be used, and identifies how to improve the use of such methods in studying quality of care. Focus groups and cognitive interviews are now a standard part of the development of valid and reliable survey instruments. They are particularly useful in developing surveys to gather data on the experiences and responses of patients and consumers to plans, services, and providers. These two methods have also been adapted and applied to improve the development and dissemination of comparative quality reports to consumers and other audiences, while key informant interviews and focus groups have been critical in the exploratory assessment of stakeholder responses to reports and their effects on consumers. Interviews have also been used to identify best practices found in health plans receiving high scores on the Consumer Assessment of Health Plans Surveys and measures of effectiveness in the Health Employer Data and Information Set. It would be valuable to widen the use of qualitative methods, especially structured observations, to document in detail the delivery of services designed to improve quality, so the implementation of complex processes can be more carefully measured and related to outcomes. The design and conduct of rigorous qualitative research takes a skilled and experienced team. Issues commonly faced in quantitative work must also be addressed in qualitative studies, including study design, specification of the unit of analysis, sampling, instrument design and administration, and, in particular, data analysis. It is especially critical that the analysis and interpretation process be deliberate and thorough to avoid the use of initial impression rather than detailed examination of the raw data.     

Teaching medicine in general practice: the Guy''s experience

The development of teaching in general practice at Guy's Hospital Medical School is described. Important features of the current programme (a new programme for the United Schools of Guy's and St Thomas' Hospitals will come into effect this year) are the emphasis on learning directly from patients and the active role and responsibility given to clinical students. Students welcome the opportunities to see patients first, to deal with undifferentiated problems, to work with one clinical teacher, to put to use knowledge and skills and to test themselves as clinicians. In these circumstances they gain confidence and display the human qualities required of doctors. An acceptable service to patients, the essential basis for effective clinical teaching, requires the general practitioner teachers devote more of their time to service than to clinical teaching.     

Empowering research: statistical power in general practice research

BACKGROUND: Statistical power is a measure of the extent to which a study is capable of discerning differences or associations which exist within the population under investigation, and is of critical importance whenever a hypothesis is tested by statistics. Conventionally, studies should reach a power level of 0.8, such that four times out of five a false null hypothesis will be rejected by a study. Statistical power may most easily be increased by increasing sample size. OBJECTIVE: We aimed to assess the level of statistical power of general practice research. METHODS: A total of 1422 statistical tests in 85 quantitative original papers in the British Journal of General Practice were analysed for statistical power. RESULTS: The median power of tests analysed was 0.71, representing a slightly greater than two-thirds likelihood of rejecting false null hypotheses. Of 85 studies, 37 (44%) attained power of 0.8 or more. Ten studies had power of more than 0.99 suggesting 'over-powering'. Twenty- one of the papers surveyed (25%) had a likelihood of gaining significant results poorer than that obtained by tossing a coin when a null hypothesis is false. CONCLUSION: While achieving higher power than studies in similar surveys of other disciplines, the power of general practice research falls short of the 0.8 convention. Adequate power is essential so that effects which exist are not missed. Recommendations are made concerning power calculations prior to the start of research and reporting of results in journal articles.      

Qualitative methods in environmental health research

Public health researchers increasingly turn to qualitative methods either on their own or in combination with quantitative methods. Qualitative methods are especially important to community environmental health research, as they provide a way to produce community narratives that give voice to individuals and characterize the community in a full and complex fashion. This article first traces the legacy of qualitative research in environmental health, then uses a case study of the author's experiences studying the Woburn, Massachusetts, childhood leukemia cluster to provide personal and scholarly insights on qualitative approaches. That material then informs a discussion of important components of qualitative methods in environmental health research, including flexible study design, access, trust, empathy, and personal shifts in the researcher's worldview, bias, and the nature of the researcher's roles. A concluding discussion addresses issues in funding policy and research practices.     

Qualitative methods for intervention research

Intervention research takes place in field settings and requires understanding of social meanings and social processes. These are tasks for which qualitative research methods are well suited. The purpose of this paper is to provide a starting point for those who would like to learn more about the qualitative research methods used in disciplines where the study of social phenomena in naturalistic settings is common—particularly sociology, cultural anthropology, and human services program evaluation. The paper discusses some ways that qualitative and quantitative methodologies can usefully work together, outlines four key differences in the initial premises of quantitative and qualitative research approaches, briefly reviews some methodological techniques useful in gathering and analyzing qualitative data, and provides suggestions for further reading on various aspects of qualitative research. © 1996 Wiley-Liss, Inc.     

Qualitative health research in the era of evidence-based practice

Evidence-based health care (EBHC) sets the tone in health care and health care research nowadays. Qualitative health researchers have to position themselves in a world that is dominated by it. The popularity of EBHC is not due to the rationality of its tenets. In this article, the author addresses major problems in EBHC. Qualitative research is important for providing the understanding that is necessary to apply findings from quantitative research properly and safely. Basic studies about the human experience in illness and regarding human behavior and meaning in general remain of great value, even in the era of EBHC. Qualitative research also plays an important role in developing scholarship.     

A house officer in general practice: a different experience

This paper describes a single house officer's attachment in general practice, organized in a particular way and with specified aims. The attachment required careful planning and case-by-case supervision of the houseman. However, the extra clinical burden on the supervisor was not excessive. The attachment provided experience similar in some ways to hospital posts, but was broader in general clinical content and emphasized the continuity between primary and secondary care. Many of the important experiences could only be obtained in an attachment which involves responsibility inside and outside the hospital at the same time. We believe such attachments are a unique educational opportunity and should be strongly encouraged.     

Shared decision making in consultations for hypertension: Qualitative study in general practice

BackgroundHypertension is mainly managed in primary care. Shared decision making is widely recommended as an approach to treatment decision making. However, no studies have investigated; in detail, what happens during primary care consultations for hypertension.AimTo understand patients’ and clinicians’ experience of shared decision making for hypertension in primary care, in order to propose how it might be better supported.DesignLongitudinal qualitative study.SettingFive general practices in south‐west England.MethodInterviews with a purposive sample of patients with hypertension, and with the health‐care practitioners they consulted, along with observations of clinical consultations, for up to 6 appointments. Interviews and consultations were audio‐recorded and observational field notes taken. Data were analysed thematically.ResultsForty‐six interviews and 18 consultations were observed, with 11 patients and nine health‐care practitioners (five GPs, one pharmacist and three nurses). Little shared decision making was described by participants or observed. Often patients’ understanding of their hypertension was limited, and they were not aware there were treatment choices. Consultations provided few opportunities for patients and clinicians to reach a shared understanding of their treatment choices. Opportunities for patients to engage in choices were limited by structured consultations and the distribution of decisions across consultations.ConclusionFor shared decision making to be better supported, consultations need to provide opportunities for patients to learn about their condition, to understand that there are treatment choices, and to discuss these choices with clinicians.Patient or Public ContributionA patient group contributed to the design of this study.     

Qualitative methods in operations research on contraceptive distribution systems: a case study from Nigeria

This article discusses the application of qualitative methods in operations research on a family planning service delivery system. Market traders in Ibadan, Nigeria were trained to sell oral contraceptives, condoms, and spermicidal foaming tablets in a collaborative research project of the Fertility Research Unit of the University College Hospital, Ibadan, and the Center for Population and Family Health of Columbia University. Focus group discussion, participant observation, and semi-structured interviews were used to investigate the cultural acceptability of distribution of contraceptives in the market places and the motivations of participating traders. The strength of the market associations was a factor influencing acceptance of the project and the number of customers for the traders' other wares were found to positively influence the volume of sales of contraceptives. Traders were motivated by the status associated with participating in a program of a well-known health institution. Findings from qualitative research suggest areas for quantitative studies and vice versa in an interactive process.     

Using focus groups in general practice research

Recent years have seen a growing recognition of the appropriatenessof qualitative methods in family practice. This has been paralleledby an upsurge of interest in focus group discussions as a method.Drawing on the experience of using focus groups with generalpractice teams as one component of a multi-method study thispaper explores emergent orthodoxies regarding the use of focusgroups and reviews the contribution which this method can maketo research in general practice.     

Opportunistic screening for Chlamydia in general practice: the experience of health professionals

Chlamydia trachomatis is the most common curable bacterial sexually transmitted infection in the UK. The infection is asymptomatic in up to 70% of women, and if untreated, can lead to pelvic inflammatory disease, ectopic pregnancy and infertility. Chlamydial infection can be diagnosed using urine testing and is easily treated with antibiotics. In 1999, the UK Department of Health funded a pilot opportunistic Chlamydia screening programme in two health authorities. All sexually active women between the ages of 16 and 24 years attending general practices and other healthcare settings, such as family planning clinics, antenatal clinics and genito-urinary medicine services, were offered the opportunity to be screened for Chlamydia, regardless of the purpose of their visit. This evaluation was funded to assess the feasibility and acceptability of opportunistic screening. The evaluation was conducted using both qualitative and quantitative methods. The present paper describes findings from the qualitative evaluation study arising from the health professionals' experience of opportunistic screening in general practice. Receptionists were central to the opportunistic screening model in general practice and it was this aspect of the model that raised most concerns. Whilst general practitioners reported that the involvement of receptionists saved them time, the receptionists themselves were sometimes drawn into discussions for which they felt ill equipped and unsuitably located. This research suggests that a call-recall national screening programme would provide a better model to undertake Chlamydia screening in general practice. The advantages of this model are threefold. First, each individual within the target age range can receive information about Chlamydia through the post. Secondly, the test and more detailed information can be managed by a practice nurse in a private and confidential setting. Thirdly, individuals are not repeatedly offered the test when visiting the surgery.     

Qualitative research and family practice: a marriage made in heaven?

Recent years have seen the development of interest in the usefulness of qualitative methods in family practice research. This paper shows how the underlying concerns of family practice medicine parallel those of the qualitative research tradition. After contrasting the philosophical underpinnings of both quantitative and qualitative methods, we go on to describe the methodological commitments of qualitative research. We relate this emerging debate within family practice to that which has taken place in other disciplines, particularly that of education. We discuss the relative strengths of qualitative and quantitative methods, and argue that these two traditions have complementary contributions to make to the discipline of family practice medicine.