Lower urinary tract dysfunction is a common and distressing problem. With functional, psychological and social sequel, it can have far-reaching effects on everyday life for individuals affected and others. Over 25 years ago, Patrick Bates coined the phrase ‘the bladder is an unreliable witness’, meaning that no matter what the underlying pathophysiology, the bladder has a limited means of expressing its own pathology. But what about those to whom these bladders belong? There is increasing recognition that what matters to most women with chronic illness is how well they are able to function and how they feel about their day-to-day lives. Understanding patients concerns, expectations and requests is important for the measurement of healthcare quality, the delivery of health services and the costs of care.
What is qualitative research?
A qualitative ‘approach’ is a general way of thinking about conducting qualitative research. It describes the purpose of the qualitative research, the role of the researcher(s), the stages of research and the method of data analysis. Qualitative research, like quantitative research, embodies a number of different theoretically based approaches1 (Box 1).
|• Ethnography is research with an emphasis on studying an entire culture. Originally, the idea of a culture was tied to the notion of ethnicity and geographic location, but it has been broadened to include virtually any group or organisation.|
|• Phenomenology is a school of thought that emphasises a focus on people’s subjective experiences and interpretations of the world. That is, the phenomenologist wants to understand how the world appears to others.|
|• Grounded theory is a complex iterative process. The research begins with the raising of generative questions that help to guide the research but are not intended to be either static or confining. As the researcher begins to gather data, core theoretical concept(s) are identified. Tentative linkages are developed between the theoretical core concepts and the data.|
Qualitative research is distinguished by an emphasis on trying to look at things from the perspective of those being studied. Qualitative methods can be particularly useful in areas where little research exists. The systematic observation of everyday behaviour, interactions and talk is especially useful in studying health issues because it allows researchers to examine what people actually do rather than relying on reported behaviour. This is something a quality-of-life questionnaire attempts to measure but does not succeed in its entirety.2
For example, urgency, defined as the compelling feeling of impending incontinence that is difficult to defer,3 is the cornerstone symptom of overactive bladder. Unfortunately, controversy continues to surround this term, its definition and its relationship to the normal urge to void. Qualitative research would be the ideal tool to unravel these uncertainties to explore the relationship of the symptom to existing measures of bladder function and symptom severity.
Where is the qualitative research?
Qualitative research continues to become more prominent in medicine and health services research. Recent editorials have advocated a larger role for qualitative research as a way to address both ‘clinical’ and ‘biopsychosocial’ phenomena,4–6 and increasing numbers of papers reporting qualitative studies have begun to appear in prominent journals. However, only 16 of 3146 abstracts accepted at International Continence Society annual conferences over the past 5 years (2002–2006) presented findings from qualitative research despite a range of areas of investigation where qualitative work would offer a valuable insight. A similar picture can be seen from examining the abstracts presented at the International Urogynaecology Association meeting of 2007. Only 3 (0.6%) of the 497 abstracts (oral podium, oral poster, nondiscussed poster and videos) were presentations of qualitative research.
So, what is the place of qualitative research in urogynaecology?
The potential purposes for which qualitative research might be used in relation to urinary incontinence are multiple:
Generating/clarifying the hypothesis
Clinical measurement is at the heart of biomedical research, but what if the measurements are not as reliable as we suppose? We generally accept that the 1-hour pad test is an objective measure of urinary incontinence, although its reliability has been challenged.7 The same is certainly true of the standard urodynamic test. There may be a paradoxical situation, as seen in clinical practice, where urodynamic tests that are thought to be objective may be found to be unreliable, and so of little clinical value,8 while urinary symptoms assessed by the women that are thought to be subjective may be found to be reliable, and so of greater clinical value.
Exploring new ground/theories
While qualitative and quantitative research may well investigate similar topics, each will address a different type of question. For example, in relation to adherence to drug treatment, a quantitative study will be used to determine the proportion and demographic characteristics of women taking a certain percentage of prescribed drugs over a given period. Questions about the reasons for variations in adherence and the meaning of drug treatment in the lives of women may be best investigated by a qualitative approach.9 Such investigation becomes very important if want to understand the reason for noncompliance to anticholinergic medications or duloxetine, for example.
Understanding quantitative study findings
Researchers can use qualitative findings to better understand quantitative results and to enhance the validity of the study as a whole. The real value is the in-depth understanding that qualitative work can give us. While qualitative data can answer ‘what?’ and ‘how many?’ qualitative methods can really get at ‘why?’ questions. All qualitative data can be quantitatively coded in an almost infinite variety of ways.
Numbers in and of themselves cannot be interpreted without understanding the assumptions that underlie them. All quantitative data are based on qualitative judgement. Let us take, for example, the International Consultation on Incontinence questionnaire Short Form (ICIQ SF) questionnaire. The question on ‘Overall how much does leaking urine interfere with your everyday life?’, which is to be answered on a scale of 0–10, requires the participant to make a judgement about what the numbers mean. We cannot really understand this quantitative value unless we dig into some of the judgements and assumptions that underlie it and explore them.
Understand perplexing results
Qualitative research may explain why the results of quantitative research based on large groups of women may be irrelevant to subgroups or individuals. Ethnography can be applied to urogynaecology as a way of accessing beliefs and practices, allowing these to be viewed in the context in which they occur and thereby aiding understanding of behaviour surrounding health and illness.10 This is particularly valuable as women’s views and experiences of illness or delivery of service become increasingly central to a 21st century healthcare system. Ethnography can show, for example, how the effectiveness of therapeutic interventions can be influenced by women’s cultural practices11 and how ethnocentric assumptions on the part of professionals can impede effective health promotion.12 This could be useful in understanding prevalence, attitudes and help-seeking behaviour in women with urinary incontinence from different ethnic backgrounds. Qualitative research may help explain contradictory results not by determining which is correct but by explaining why they differ.
Assessing the outcomes of treatment
Outcome evaluation has been seen primarily as the preserve of quantitative research. Owing to the subjective symptomatic nature of the quality-of-life impact associated with voiding dysfunction and incontinence, there is no gold standard for outcomes assessment. Patients’ perceptions of their condition, physicians’ analyses of therapy (with or without investigator bias) and the real probability of incomplete symptomatic response to intervention each contribute to the difficulty of evaluating the success of any therapy. For women to have a realistic expectation of outcome, it is important to understand their expectations and priorities beforehand.13 Existing studies suggest that women regard improved symptoms and quality of life as the most important outcomes of treatment.14 Most women want ‘a good improvement so that symptoms no longer interfere with their life’.15 This might suggest that good patient perceptions can be obtained without achieving total continence. But how are we to find this if we only use objective assessments to define cure?
Choosing the most effective treatment for urinary incontinence is not necessarily going to result in a satisfied woman if they are unprepared or if their expectations remain unfulfilled, and qualitative research can provide information to help in the counselling of women about these issues. This in turn may improve patient satisfaction and long-term compliance. We need a broad spectrum of information if we are to understand not only which treatments work but also how and why they work (or do not work).
Complementing quantitative research
Qualitative research can both inform and complement quantitative research. For example, interviews are frequently used in questionnaire development to check the meaning of words or terms to be used or to validate individual questions. This preliminary research is often a vital stage in survey research. Thus, all quality-of-life questionnaires must have been developed after extensive qualitative research to make them robust and user friendly.
Qualitative methods can improve service provision
Qualitative methods can help plan the locations or settings for intervention, especially if the intervention is to be community based or mobile, where the precise location of the service is crucial. For example, it is important to understand the targets populations’ profiles, needs and help-seeking-related experiences, before setting up a service, especially among hard-to-reach groups.
By using a multi-indicator approach, qualitative methods can complement quantitative and monitoring research to address the three key questions often asked in process delivery—is the service being delivered? Is it being delivered as planned? Is it reaching the target population? Interviews with both staff and clients can gain insight into the barriers and facilitators of service delivery as well as gaining measures of satisfaction. It can be readily seen how this kind of information can help integrated continence services around the country to provide appropriate and cost-effective care.
So, why has qualitative research struggled?
Despite offering a valuable insight into other chronic illness over the course of several decades, qualitative research has struggled to penetrate urogynaecology. One reason may be that clinical scientists have had difficulty in accepting the research methodologies of the social sciences. Publication and dissemination of the results of qualitative research have often been difficult, partly because different formats are required. A narrative, as opposed to numerate, account of an investigation may not fit into a typical biomedical journal or into a 10-minute presentation at a scientific meeting. The assessment of proposals for qualitative research and of papers submitted for publication is likely to have been hampered by a lack of agreement on criteria for assessment. Most referees are more familiar with the concepts of quantitative research (including generalisability and a large sample) and may simply transfer these thought processes to their assessment of qualitative research, although this is inappropriate. It is possible, however, to provide clear guidance to reviewers how to assess qualitative research.1
Urinary incontinence and lower urinary tract dysfunction are common conditions, and no one would deny that much more knowledge into appropriate patient-centred assessment outcomes and ultimately prevention is required. There are many goals to research, including to improve the care of women, and also to promote understanding of the disease process.
Gilchrist and Engel16 wrote that ‘qualitative research answers questions for clinicians that quantitative research cannot. These are questions about individuals’ motivations, perceptions, expectations, and meaning’.
The ultimate goal is to produce credible research, and the bottom line is that quantitative and qualitative data are two sides of the same coin. To ask which is ‘better’ or more ‘valid’ ignores the intimate connection between them. To do credible research, we need to use both the qualitative and the quantitative data.
Declaration of interest
A declaration of interest statement can be found in the online version of this paper.