Qualitative and mixed methods methodology are becoming more commonplace in otolaryngology as the field strives to understand more complex concepts of the ear, nose, and throat. Qualitative methodology can have tremendous utility in studies directed at patient-centered care by offering practical insights and granular detail—directly from patients—which may not be realized by quantitative approaches.
In this article, we want to focus on which questions can be answered by qualitative research, review the basics of the underlying principles and different methodologies used, and describe the pearls, pitfalls, and rigor of qualitative research. This understanding of qualitative inquiry is critical for otolaryngologists who want to stay current on what’s published and can include this in their research repertoire.
There’s been a recent increase in the use and prominence of qualitative methodology in health services research. Historically, qualitative methods have been underused in clinical research relative to quantitative approaches. The value of quantitative research has already been recognized in multiple fields of medicine (World Neurosurg. 2022;161:441–449; Clin Exp Dermatol. 2022;47:2090–2095). Moreover, a recent study found that both quantitative and qualitative research had a similar academic impact based on bibliometric and altmetric measures (BMJ Open. 2020;10:e040950).
Qualitative methodology may be used on its own or incorporated into a mixed research approach as a complement to quantitative methods to study especially complex problems. For example, a qualitative study can generate a hypothesis for quantitative research. Alternatively, quantitative research may lead to findings that can be further clarified with qualitative study.
As qualitative methodology begins to pervade the otolaryngologic literature (Clin Otolaryngol. 2018;43:1443–1453; Otolaryngol Head Neck Surg. 2023;168:862–867), otolaryngologists need to understand the questions qualitative research can answer, the types of qualitative methodology to use to answer these questions, and ways to critically evaluate qualitative studies when reading or when asked to review these studies.
What Is Qualitative Research?
Qualitative research has been described as “an interpretive, naturalistic approach to the world” in which “researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them” (The SAGE Handbook of Qualitative Research. SAGE, 2011). The final product of qualitative research “includes the voices of participants, the reflexivity of the researcher, and a complex description and interpretation of the problem and its contribution to the literature or a call for change” (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018).
Overall, the goal of the researcher is to describe the lived experience, event, or phenomenon in detail through non-numerical data collection, often using words or themes. Qualitative research is often implemented through participant interviews, focus groups, or observation of people in their natural environments. The aim is to obtain the views, perspectives, and perceptions of those being studied and to accurately portray and communicate these findings.
There are certain themes that characterize qualitative research. It’s important to gather information from participants in their natural setting by interacting with and talking directly to the study participants where they’re comfortable and not through surveys or in a lab setting (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018). The researcher is often as much an instrument of the research as they are part of the data-gathering process. Both inductive and deductive logic are used to work from granular detail—at the most basic level, a collection of words—to more abstract units of information, leading to comprehensive themes. Then, researchers iteratively discuss those themes with participants to ensure that the final message is congruent with the participants’ perspectives.
Different participants may have different perceptions, leading to diverse views of reality, or there may be multiple “truths,” none of which are correct or incorrect but which instead represent the spectrum of the phenomenon. In fact, qualitative studies typically recruit study participants in numbers specifically to reach thematic or content saturation—i.e., to identify the full spectrum of perspectives and truths. It’s important to realize that these views are context dependent (e.g., historical, social, political), and this context should be clearly communicated when publishing the results of the study. It’s also acceptable to be flexible as the study progresses, understanding that in the beginning the researcher may have some idea of the phenomenon, but that the understanding may shift as the researcher learns more about the phenomenon from the participants.
Finally, when reporting findings, much as in other forms of research, the researcher should also declare their motivation to study the topic and list any possible personal biases associated with the topic, as this may inform how the researcher interpreted the data (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018).
Why Conduct Qualitative Research?
As previously mentioned, qualitative research can capture the granular context of the human experience, which is certainly at the heart of what many otolaryngologists face when attempting to solve clinical problems of the ear, nose, and throat. The ability to communicate with the world through the senses, enjoy food, socialize, breathe well, and have a good quality of life are all human experiences that an otolaryngologist helps his or her patients to achieve. Studies of numbers and outcomes may not fully explain the complex nature of these clinical problems and the patients’ experiences. Qualitative study can help bridge this gap.
A qualitative study may be particularly useful when there’s no previous understanding of a subject. In this case, a qualitative study can generate hypotheses for future quantitative studies. For example, the key stakeholders of a poorly understood concept might be interviewed to clearly define parameters that could later serve as quantifiable outcome measures. The outcomes of these qualitative studies might be transformative, perhaps offering surprising realizations or changing the way the concept is thought of.
Alternatively, a quantitative study may give an unexpected result without an understanding of the why; a qualitative study could then help researchers understand the why. Qualitative studies can also be particularly useful when evaluating processes, life cycles, and the scope of a medical condition that might not be otherwise observable or fully captured in a survey or quantitative study.
How to Conduct Qualitative Research
Much like quantitative research, qualitative research starts with the scientific method: A hypothesis or question is developed, a study or methodology is planned, data are collected, and the results are then analyzed and reported. The initial process involves performing a literature review to understand what’s already known and then developing a question to study with a corresponding hypothesis.
Additionally—and perhaps unique to qualitative research—there’s also an emphasis on understanding the philosophical assumptions of the research team and research participants at the onset of the project:
Ontological assumptions describe the view of reality, both from the perspective of the researcher and those being researched. It’s important for researchers to acknowledge and support that these may be different views of the same reality as key themes are developed. For example, a researcher who studies the reality of HPV under-vaccination rates in children may encounter some parents’ perceptions that, after a previous bad encounter leading to distrust in the medical system, vaccination may be dangerous to their child, as well as some physicians’ perceptions that, while vaccination is safe in children, they personally don’t have time to offer it in their clinics, contributing to under-vaccination rates.
Epistemological assumptions are what can be described as “knowledge,” and are applied to qualitative research with the assumption that the researcher wants to understand as accurately as possible the participants’ lived reality. From a practical perspective, epistemological assumptions may be implemented through direct quotations from the participant as evidence of the participant’s knowledge of their reality. For example, a researcher studying what’s most important for end-of-life care in head and neck cancer patients may use direct quotations from the patients to express key knowledge, such as, “I feel the most important thing to me is to die at home in peace.”
Axiological assumptions include the understanding that all researchers have biases, and that this should be acknowledged within the context and setting of the research. For example, a researcher studying head and neck cancer survivorship and wellness may have a bias against survivors who continue to smoke tobacco.
Therefore, at the beginning of a qualitative research project, it’s important to understand and acknowledge the assumptions the researcher brings to the project and then decide if these assumptions will be actively incorporated into the project and disclosed when reporting the findings.
Once these assumptions are considered and the decision has been made whether to incorporate them into the study’s framework, the research team then picks a research methodology to best capture their question.
There are several research methodologies within qualitative research, and new methods are always being developed. The five types of qualitative research methodology that are described here are the most likely to be employed in otolaryngology research:
Narrative research is used to capture the detailed stories and life experiences of one individual or a small group in a similar setting by using multiple sources of information, such as personal documents, public records, and interviews with the individual or people who knew the individual. Findings from this research are often presented as a chronology of events (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018; BMJ Open. 2016;6:e011220). For example, how do patients with laryngectomies [the individuals] navigate activities of daily life challenges [the lived experience] in the first 30 days after hospital discharge?
Ethnography is used to describe the lived experience of a culture-sharing group by depicting and interpreting the values, beliefs, and behaviors of the group. The researcher often goes to the group’s natural environment and performs extended observation of interactions. Analysis is usually based on 20 or more individuals within the group and includes extensive observation within the community to get an adequate representation of the group (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018; Disabil Rehabil. 2021;43:3271–3275; Med Teach. 2013;35:e1365–e1379). For example, a researcher goes to live among a rural population for four months to observe and understand what factors contribute to the lack of cochlear implantation [the lived experience] for those who qualify in rural populations [culture sharing group].
Phenomenology is aimed at describing a phenomenon or concept by gathering the lived experiences of several individuals. The researcher aims to capture enough information about a particular phenomenon to reduce everyone’s lived experience to a “common essence.” This concept is then explored with the individuals who experience this phenomenon to ensure its accuracy and validity. Sample sizes vary from three to five, to 10 to 15 individuals, based on the complexity and congruency among subjects, until saturation bias is reached (i.e., subjects don’t describe anything about the concept beyond what has already been described) (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018; Perspect Med Educ. 2019;8:90–97). For example, what factors contribute to the delayed diagnosis [phenomenon] of vocal cord dysfunction some female athletes [individuals] experience?
Grounded theory aims at developing a theory, usually about some movement or action that’s grounded in participant data. The methodology is quite iterative, with a process involving interviewing participants or examining documents to develop a theory and then taking that theory back to the specific population to validate it. This methodology employs open, axial, and selective coding, referring to first taking the text and breaking it up into discrete open codes, then connecting different codes by drawing connections between them (axial), and then finally developing a central code that captures the essence of the theory (selective). Typically, this research involves 20 to 30 subjects to achieve data saturation, although this can certainly vary with subject matter (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018; J R Coll Physicians Edinb. 2015;45:201–205). For example, what are the factors that contribute to the low rate of HPV vaccination [theory] in the United States’ pediatric population [relevant group] today?
A case study involves the analysis of a particular individual, small group, or small organization (bound by time and context) through interviews, documents, and direct observations to describe an individual case or case series (Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE, 2018; J Adv Nurs. 2009;65:1171–1181). For example, what factors lead to successful implementation of an otolaryngology-based unit to care for post-reconstructed head and neck cancer patients in a high-volume tertiary care hospital?
Once the question has been defined, the assumptions understood, and the methodology defined, data collection can begin. Greater diversity of thought within the participant group and diversity in types of data examined will ultimately be more helpful in providing the necessary content to comprehensively describe the granular complexity of a subject. Data are often collected either through written information from focus groups, or through direct observation or interviews. Interviews are often semi-structured, meaning that there are predetermined open-ended questions that promote two-way communication. This allows comparison among interviews but still allows participants the flexibility to spontaneously bring up other topics. Once written or transcribed, data can then be stored in coding software packages.
Data analysis is often started before all data are collected. Periodic, interim data analyses can provide insights into the direction of the remainder of the study or unanticipated knowledge gaps that need to be investigated further.
As data analysis continues, the raw data go under multiple abstractions to broaden themes and eventually converge on a described conceptional model. Often, this involves a group of researchers and multiple, iterative conversations over time to identify and determine central themes. This final product represents the participant’s perspective through the lens of the researcher’s interpretation to form a theoretical or conceptual framework. These results are often brought back to the participants, or a new set of participants within the same population, to validate.
Ethics of Qualitative Research
Above and beyond the basic requirement of Institutional Review Board approval for research studies on human participants, there are research ethics specific to qualitative research that must be considered. A researcher must acknowledge their assumptions at the beginning of the project to understand their own biases and decide whether to incorporate them into the methodology or actively avoid them during the project. Furthermore, if the topic covers sensitive material that a participant may be fearful or embarrassed to discuss, a researcher will specifically want to avoid stereotypes, power dynamics, and placing participants at risk.
For example, if an investigator is the treating physician of a participant, it may be wise to have someone else conduct an interview to avoid a potential power dynamic, which could make the participant uncomfortable about speaking freely. Participant anonymity and privacy are also of particular importance when sensitive subjects are discussed. Therefore, removing any type of identifying information is critical to keeping participants safe and allowing them to express their true lived experience.
When recruiting, researchers should also disclose the motivation, purpose, and objectives of their study to participants so there’s transparency from the onset. Ideally, the topic and findings should give some benefit to the participant group so there is some reciprocity for participating.
Pearls, Pitfalls, and Rigor
While there aren’t many otolaryngologists who are experts in qualitative research, there are qualitive research experts at most academic centers and private companies who specialize in qualitative research. If you aren’t an expert in qualitative research, it’s often good to “load the boat” and incorporate the expertise of qualitative researchers when performing these studies. This can be particularly helpful when making decisions about which methodology would be best suited for a particular question. Multidisciplinary collaboration can be particularly advantageous in these settings, bringing two different fields together to address common problems in otolaryngology.
Just as with quantitative research, there are challenges associated with qualitative research. Qualitative research takes time—time to understand the topic through a comprehensive literature review, time to examine biases, and time to decide how to handle those biases. There may also be time associated with gaining access to and establishing rapport with a population, especially vulnerable populations. There’s a considerable amount of time associated with data collection and analysis—reading and coding raw data, developing key insights, refining research protocols, and potentially gathering more raw data.
Another potential pitfall involves participant sample size. Based on the methodology, the number of subjects may be as small as 1 or as large as 30, but it isn’t often larger than that. At the beginning of a study, a researcher may have an estimate of how many subjects are needed, but they can’t be sure until data analysis is performed. This differs from quantitative research, where statistical power and sample size calculations are predetermined.
To understand if an appropriate sample size has been reached, a researcher must examine their data and evaluate information gathered to spot repeated themes. At that point, data saturation has been reached.
Finally, there must be validity and authenticity to the data and results. Four criteria have been developed to help ensure rigor in qualitative research: credibility, dependability, transferability, and confirmability (Naturalistic Inquiry. Sage Publications, 1985).
- Credibility occurs if the research question, methodology, and data analysis are well aligned, plausible, and trustworthy.
- Dependability refers to the ability to replicate the study based on the described methodology.
- Transferability means that the study context has been described in enough detail so that it’s easy to determine if the results are applicable to a population.
- Confirmability evaluates the relationship between the data analysis and key findings to ensure that the data support the conclusions.
Several checklists incorporate these four quality control concepts. One that is commonly used is the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist that’s useful to review at the start of a study, during data collection, and during manuscript preparation (Int J Qual Health Care. 2007;19:349–357).
Qualitative research can provide an in-depth evaluation of these topics to reveal key insights into the common issues we treat. Much like quantitative research, it’s time consuming and requires extensive planning, but it can be rewarding and can lead to a successful research career.
Dr. Phillips and Dr. Sedaghat are from the department of otolaryngology–head and neck surgery at the University of Cincinnati College of Medicine in Ohio. Dr. Tichavakunda is from the department of education leadership at the University of Cincinnati.