We had no idea in 1996 that, more than two decades later, we would be embarking on a fourth edition of this book. When we wrote the original paper [1] which inspired the book, qualitative methods were largely unfamiliar to health professionals and many health care researchers. Indeed, there was indifference and even hostility in some circles to the use of qualitative methods in research on health care. The paper that led to the book had been based on a quirky dramatic conference presentation to the Society for Social Medicine's annual scientific meeting in the form of a Socratic dialogue between a young female qualitative health services researcher and her older, male, medically trained boss. Crudely, the question the dialogue explored was: ‘Why don't medics take qualitative research methods seriously?’ The intervening years have seen a huge expansion in the use of these methods in health care research and elsewhere. For example, the place of qualitative research is now sufficiently recognised at the highest level in government to merit the commissioning, by the UK Cabinet Office, of a guide for civil servants and researchers on how to assess the quality of qualitative policy evaluations [2].

Following the publication of the initial Socratic dialogue, we were fortunate that Richard Smith, the sympathetic then editor of the British Medical Journal, accepted our proposal for a series of papers targeted largely at clinicians, introducing them very succinctly to the main methods used in qualitative research in health care. This series became the first edition. The book has since become international – having been translated into Japanese and Portuguese [3, 4] – and we find that its readership now includes health care professionals working in many different health systems, researchers from diverse disciplinary backgrounds, and policy‐makers and research funders from across the globe. This book is also now one of several on the application of qualitative research to health care, but we believe that it remains distinctive as an entry point for those with little or no previous knowledge of qualitative methods.

For the fourth edition, we have updated the existing material, incorporating new examples and references, and added new chapters on topics which we see as increasingly relevant in an introductory text. As well as continuing to introduce the core qualitative methods of interviews and observation, the book includes entirely new chapters covering the analysis of documents and visual artefacts, and of virtual and digital data, which are becoming more widely used in the health research field. Also new to this edition is a chapter on the role of theory in qualitative research, which we have added in response to requests from readers and students anxious to understand the intellectual foundations of qualitative research. Looking back at previous editions of this book, we feel that we avoided or minimised attention to debates about theory and philosophy in a way that suggested they were irrelevant to qualitative research in health care. In this edition, we recognise the importance of theory in qualitative research more explicitly. We view theory as the foundation of what we do, and, like the physical foundations of a building, while the structures may not be immediately visible, they support what we do as researchers. This book also examines the interface between qualitative and quantitative research – in primary ‘mixed method’ studies and case study research, and in qualitative secondary analysis and evidence synthesis.

Preparing this fourth edition took a lot longer than we had anticipated, in part because as editors we have reached a stage of life characterised by significant caring responsibilities, notably for relatives who need formal health and social care, and informal support. Our interactions with the health and social care services in this period have sharpened our belief that the methods and approaches described in this book are needed to understand health care and health services, and will be essential if we are to improve these. We owe a debt of thanks to all the authors for contributing to this new edition, and to them and our publishers for their patience with the elongated editing process.

As before, this book has been improved by the constructive advice, commentary, and expertise of colleagues and students, readers, and reviewers. Other researchers have made our job easier by opening up and contributing to debates about methodology and research quality, and by simply doing the kinds of qualitative research which we refer to in this book. We are grateful to the team at Wiley: Pri Gibbons and Deirdre Barry in Oxford, and, in particular, our Project Editor, Yoga Mohanakrishnan and Production Editor, Bhavya Boopathi in India.

References

1. 1 Pope, C. and Mays, N. (1993). Opening the black box: an encounter in the corridors of health services research. BMJ 306: 315–318.
2. 2 Spencer, L., Ritchie, J., Lewis, J., and Dillon, L. (2003). Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence. London: Government Chief Social Researcher's Office, Prime Minister's Strategy Unit, Cabinet Office. https://www.gov.uk/government/publications/government‐social‐research‐framework‐for‐assessing‐research‐evidence (accessed 15 September 2019).
3. 3 Pope, C. and Mays, N. (2001). Qualitative Research in Health Care. Tokyo: Ikakju‐Shoin Ltd.
4. 4 Pope, C. and Mays, N. (2005). Pesquisa qualitative an atenção à saúde (trans. A.P. Fajardo). Porto Alegra: Artmed.

Davina Allen

School of Healthcare Sciences
Cardiff University
Cardiff, UK

Rebecca K. Barnes

Centre for Academic Primary Care
University of Bristol
Bristol, UK

Nicky Britten

College of Medicine and Health
University of Exeter
Exeter, UK

Alec Fraser

King’s Business School
King’s College London
London, UK

Dawn Goodwin

Lancaster Medical School
Lancaster University
Lancaster, UK

Martin Gorsky

Centre for History in Public Health
London School of Hygiene and Tropical Medicine
London, UK

Lisa Hinton

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

Bodil J. Landstad

Department of Health Sciences
Mid Sweden University
Sundsvall, Sweden

Geraldine M. Leydon

Faculty of Medicine
University of Southampton
Southampton, UK

Kath Maguire

College of Medicine and Health
University of Exeter
Exeter, UK

Nicholas Mays

Department of Health Services Research and Policy
London School of Hygiene and Tropical Medicine
London, UK

Alex Mold

Centre for History in Public Health
London School of Hygiene and Tropical Medicine
London, UK

Alicia O’Cathain

School of Health and Related Research
University of Sheffield
Sheffield, UK

Catherine Pope

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

John Powell

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

Sara Ryan

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

Jonathan Q. Tritter

School of Languages and Social Sciences
Aston University
Birmingham, UK

Michelle H. van Velthoven

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

Sue Ziebland

Nuffield Department of Primary Care Health Sciences
University of Oxford
Oxford, UK

Qualitative research is used in a range of social science disciplines. It encompasses a range of methods for data collection and analysis that are used in both academic and market research, several of which have become familiar in health care and health services research. This book aims to introduce the main qualitative methods that can be used to study health care, and to argue that qualitative research can be employed appropriately and fruitfully to answer complex questions confronting researchers. These questions might include those directed to finding out about patients' experiences of health care and everyday health care practices or evaluating organisational change processes and quality improvement.

1.1 What Is Qualitative Research?

Qualitative research is often defined by reference to quantitative research. It is seen as a way of doing research ‘without counting’ because it does not set out to quantify or enumerate the social world or phenomena studied. Indeed, the origins of this book lie in a series of articles on non‐quantitative methods directed at a medical journal audience. However, defining qualitative research as ‘not quantitative’ is unhelpful. It risks suggesting that because qualitative research does not seek to measure, it cannot help to explain or understand social phenomena. Whilst it is true that qualitative research generally deals with speech, actions, and texts rather than numbers, this does not mean that it is devoid of measurement or explanatory power. It is worth noting that it is both feasible and legitimate to analyse certain types of qualitative data quantitatively (see Chapter 9 on the analysis of qualitative data). Moreover, qualitative analysis can offer profound and rich insights about aspects of health care and services that prove elusive to quantitative research, as pointed out in a letter to the British Medical Journal on the contribution of qualitative health care research:

Qualitative studies help us understand why promising clinical interventions do not always work in the real world, how patients experience care, and how practitioners think. They also explore and explain the complex relations between the healthcare system and the outside world, such as the socio‐political context in which healthcare is regulated, funded, and provided, and the ways in which clinicians and regulators interact with industry. [1]

Qualitative research is variously referred to as an approach or set of approaches, as a practice, or as a paradigm. We describe qualitative research as an interpretative approach to data collection and analysis that is concerned with the meanings people attach to their experiences of the social world and how people make sense of that world. Qualitative research comprises both qualitative methods of data collection and qualitative methods of analysis; it gathers words and/or visual, descriptive forms of data and explicates these using text‐based, interpretative analytical methods.

Qualitative research tries to interpret social phenomena such as interactions, behaviours, and communications in terms of the meanings people bring to them. If quantitative research asks questions such as ‘how big is X or how many Xs are there?’, qualitative research tackles questions such as ‘what is X, and how do people's perceptions of X vary in different circumstances, and why?’ In this respect the ‘measurement’ that takes place in qualitative research is often concerned with taxonomy or classification rather than enumeration. This interpretive focus means that the researcher frequently has to question common sense and assumptions or taken‐for‐granted ideas about the social world. Bauman, talking about sociology in general, refers to this as ‘defamiliarising’ and this is exactly what good qualitative research tries to do [2]. Rather than simply accepting the taken‐for‐granted concepts and explanations used in everyday life, qualitative research asks fundamental and searching questions about the nature of social phenomena. So, for example, instead of counting the number of suicides, which presumes that we already agree on the nature of suicide, the qualitative researcher may well start by asking, ‘what is suicide and how is it defined in this society?’ and go on to show that it is socially ‘constructed’ by the activities of coroners, legal experts, health professionals, and individuals, so that definitions of suicide and its connotations vary considerably between different countries, different cultures and religious groups, and across time [3, 4]. These insights, in turn, have profound implications for any attempt to quantify levels or trends in suicide or to intervene to reduce the number of suicides.

A second distinguishing feature of qualitative research, and one of its key strengths, is that it is particularly suited to studying people in their day‐to‐day settings rather than in artificial or experimental ones (though, as Chapter 12 shows, qualitative methods can be used fruitfully even as part of experimental studies such as randomised controlled trials). Kirk and Miller define qualitative research as a ‘particular tradition in social science that fundamentally depends on watching people in their own territory, and interacting with them in their own language, on their own terms’ [5]. This is referred to as naturalism – hence the term ‘naturalistic methods’, which is sometimes used to denote the approach used in much, but not all, qualitative research.

Another feature of qualitative research (which some authors emphasise) is that it often employs several different qualitative methods of data collection. Studying people in their own territory can thus entail observing (non‐participant observation), joining in (participant observation), and talking to people (interviews, focus groups, and informal chatting). It might also include reading what they have written (documentary analysis) and examining objects, images and artefacts they create or use. Different qualitative methods can be combined to provide deeper insights; for example, a recent doctoral thesis used photographs to explore a health care setting augmented by interviews and focus groups [6]. Another study interrogated a range of different documents and used interviews to understand health policy [7], and elsewhere observation and interviews have been used together to examine the implementation of a major quality improvement initiative [8], and to identify the barriers to innovation in health care organisations [9].

1.2 The Uses of Qualitative Research

As well as combining several qualitative methods in a single study, quantitative and qualitative approaches can be used to complement each other. (This is explored in more detail in Chapter 12.) One simple way this can be achieved is by using qualitative research as the preliminary to quantitative research. This model is likely to be the most familiar to those engaged in health and health services research. For example, qualitative research can be used to classify phenomena, or answer the ‘what is X?’ question, which necessarily precedes the process of enumeration of Xs. As health care deals with people, and as people are, on the whole, more complex than the subjects of the natural sciences, there is a whole set of such questions about human interaction, and how people interpret interaction, to which health professionals and researchers may need answers before attempting to quantify behaviours or events. At their most basic, qualitative research techniques can be used simply to discover the most comprehensible terms or words in common use to describe an activity which can be included in a subsequent survey questionnaire. An excellent example of this can be found in the preliminary work undertaken for the British national survey of sexual attitudes and lifestyles [10]. In this case, face‐to‐face interviews were used to uncover popular ambiguities and misunderstandings in the use of a number of terms such as ‘vaginal sex’, ‘oral sex’, ‘penetrative sex’, and ‘heterosexual’. This qualitative work had enormous value in informing the development of the subsequent survey questionnaire, and in ensuring the validity of the data obtained, because the language in the questionnaire was clear and could be widely understood. This sense checking and foundational qualitative work is increasingly used in studies of complex health care interventions both to inform the development of the intervention itself and to design the evaluation. An example of qualitative work that contributed to both these aspects is Segar et al.'s careful interview and observational work that informed the development of two telehealth interventions to support patients with long‐term conditions [11], and which also contributed to the development of a conceptual framework that underpinned the randomised controlled trials used to evaluate these interventions in the Healthlines study [12].

Qualitative research is not only useful as the prelude to quantitative research. It also has a role to play in ‘validating’ quantitative research or in providing a different perspective on the same social phenomena studied quantitatively. Sometimes, it can force a major reinterpretation of quantitative data. For example, one anthropological study using qualitative methods uncovered the severe limitations of previous surveys: Stone and Campbell found that cultural traditions and unfamiliarity with questionnaires had led Nepalese villagers to feign ignorance of abortion and family planning services, and to under‐report their use of contraception and abortion when responding to surveys [13]. More often, the insights provided by qualitative research help to interpret or understand quantitative data more fully. Thus Bloor's work on the surgical decision‐making process built on an epidemiological study of the widespread variation in rates of common surgical procedures [14] (see Box 1.1) and helped to unpack the reasons why these variations occurred [15]. In the Healthlines study described earlier, qualitative research was used to explain the modest effects achieved in the randomised controlled trials of the telehealth interventions [16].

Qualitative methods can also be used independently to uncover social processes, or access areas of social life which are not open or amenable to quantitative research. They are especially valuable for understanding views and opinions. For example, Morgan and Watkin's research on people's cultural beliefs about hypertension has helped to explain why rates of compliance with prescribed medications vary significantly among and between white and Afro‐Caribbean patients in South London [17]. Qualitative research can also provide rich detail about life and behaviours inside health care settings, as in Strong's classic observational study showing how American and English hospital clinics were organised [18]. Stand‐alone qualitative research has also been useful in examining how data about health and health care are shaped by the social processes that produce them – from waiting lists [19], to death certificates [20], and AIDS case registrations [21]. Qualitative methods are increasingly being used in studies of health service organisation and policy to considerable effect in evaluating organisational reforms and changes to health service provision [22].