Open Access

Fair publication of qualitative research in health systems: a call by health policy and systems researchers

  • Social science approaches for research and engagement in health policy & systems (SHaPeS) thematic working group of Health Systems Global, Regional Network for Equity in Health in East and Southern Africa (EQUINET), and Emerging Voices for Global Health,
  • Karen Daniels1, 2Email author,
  • Rene Loewenson3Email author,
  • Asha George4, 5,
  • Natasha Howard6,
  • Gergana Koleva7,
  • Simon Lewin8, 1,
  • Bruno Marchal9,
  • Devaki Nambiar10,
  • Ligia Paina5,
  • Emma Sacks11, 12,
  • Kabir Sheikh13,
  • Moses Tetui14, 15,
  • Sally Theobald16, 17,
  • Stephanie M. Topp18 and
  • Anthony B. Zwi19
International Journal for Equity in Health201615:98

https://doi.org/10.1186/s12939-016-0368-y

Received: 4 May 2016

Accepted: 11 May 2016

Published: 22 June 2016

An open letter from Trisha Greenhalgh et al. [1] to the editors of the British Medical Journal (BMJ) triggered wide debate by health policy and systems researchers (HPSRs) globally on the inadequate recognition of the value of qualitative research and the resulting deficit in publishing papers reporting on qualitative research [2]. One key dimension of equity in health is that researchers are able to disseminate their findings and that they are taken into account in a fair and just manner, so that they can inform health policy and programmes. The Greenhalgh et al. letter and editorial responses [3, 4] were actively discussed within “SHAPES”, a thematic group within Health Systems Global, focused on Social Science approaches for research and engagement in health policy & systems (http://healthsystemsglobal.org/twg-group/6/Social-science-approaches-for-research-and-engagement-in-health-policy-amp-systems/) and within EQUINET, a regional network working on health equity research in East and Southern Africa (www.equinetafrica.org). Our discussion precipitated in this follow up open letter/commentary, which has 170 co-signatories. Collectively, we feel that barriers to publication of qualitative research limit publication of many exemplary studies, and their contribution to understanding important dimensions of health care, services, policies and systems.

While we work on different aspects of health systems, we all feel that more serious recognition of the value of qualitative research is required, including to disseminate evidence and contribute voice to advance equity in health. In the spirit of collective engagement for research excellence that makes a difference to the communities and systems with which we work, we add our voices to this debate. We are particularly disenchanted by our general experience of the limited and often inadequate publication of qualitative research in the major health and medical journals, and the resultant loss of important insights for those working in, or concerned with, health services and systems, including around clinical decision-making.

The editors of one major medical journal have, for example, asserted a desire to publish “studies with more definitive—not exploratory—research questions that are relevant to an international audience and that are most likely to change clinical practice and help doctors make better decisions” [4]. Even for medical journals, this reinforces a somewhat narrow view of health care, and of the forms of evidence relevant to clinical decision making [5]. Restricting publication to quantitative research risks marginalising important bodies of knowledge such as those concerned with the social nature of health and illness or the way in which service providers incorporate (or neglect) such knowledge. Given the complex nature of health, policy, services and systems, we would argue that more inclusive and wide ranging insights and perspectives -- rather than fragmented ones -- are required, and methodologies should not be limited to quantitative approaches [6, 7]. Doctors do not (and should not) make decisions about patients in a vacuum, but operate within the broader social, political and systemic contexts of health care. Appreciating the nature of such influences can assist in making better informed and more appropriate decisions, especially given that such influences are rarely only ‘technical’.

Given the varied influences on clinical practice, Health Systems Global has observed that such decisions must take account of relationships and complexity in health systems, and cannot be addressed through simple causality models [8]. Qualitative social science approaches have a key role in uncovering these broader relationships and complexities, and can crucially inform decision making by providing them with necessary insights and engaging them in these dynamics. A greater appreciation of the value of qualitative approaches in the study of health care systems and policy can only improve decision-making in our age of high political consciousness and rapid information availability.

Working with the World Health Organization (WHO) in developing guidance and policies for maternal health, for instance, HSG members have found a demand from policy makers, planners, and implementers for qualitative research to inform decisions on health systems and clinical recommendations and to identify implementation considerations. Important evidence has been derived from both systematic reviews of qualitative studies and mixed-methods reviews, for example on the mistreatment of women in health facilities during childbirth [9] and concerning barriers and facilitators to task-shifting in midwifery services [10] and for lay health workers [11]. These reviews have been used in guideline development and have also stimulated wider public interest and debate, as in the case of the Bohren review, which was documented in the New York Times [12]. The WHO Handbook for Guideline Development recognises the importance of such evidence and includes a chapter on using qualitative research in developing guidelines [13]. The WHO and a number of other agencies have also supported the development of a new approach to assess how much confidence to place in evidence from systematic reviews of qualitative studies [14], to facilitate using such evidence to inform health care decisions. This experience highlights the crucial roles that qualitative evidence syntheses can play in gathering qualitative evidence addressing a health question, developing new insights and theory from this evidence to inform policy and practice (including clinical practice), and identifying research gaps. The major health and medical journals should encourage the submission of such syntheses in the same way that many encourage submission of systematic reviews of the effectiveness of health interventions and of diagnostic tests.

Decisions concerning health systems and medical practice globally are taken by a range of professionals, not only or even primarily, by doctors. Multidisciplinary teams play a key role in promoting more holistic equitable models of care, and other providers are crucial in those many parts of the world where there are no or not enough doctors. Here, many decisions need to be taken by wider health care teams and clients equally involved in health promotion and care plans. ‘Biopsychosocial’ models [of care] correctly identify disorders as outcomes of interactions between biological, psychological and social determinants. Qualitative research demonstrates the subjectivity of health workers in the therapeutic alliance, relationships and communication between health workers and clients [1517], and the role of social literacy and of people’s values, preferences, and lifestyles in medical decision-making process when assessing the merits of various treatment alternatives for specific health problems [18]. The expanding literature on ‘person centred care’ recognises these issues.

Qualitative research facilitates examination of quality of interaction [19] and identifies the patient as an individual (and member of a family and community) experiencing care rather than being the subject of a disease process [17]. Mixed methods help identify and explain the factors that influence outcomes, and important dimensions of care, such as trust and social support, not all of which can be ‘measured’ by numbers alone [17]. Qualitative research also facilitates better understanding of the political and social determinants of care [20] including gender, social literacy, values, preferences [18, 21, 22]. One area where understanding these complex dynamics is pertinent, is with the deploying of lay/community health workers [23], especially since they work so close to communities [18, 24]. Despite important randomised controlled trials on the effectiveness of lay/community health workers, and a systematic review of these trials [25], the review authors argue that qualitative research is still needed to explain the complexities of the review findings [26]. This is echoed by one of our signatories:

“I do love working on numbers …, but I can only understand my findings and know how to model my data if I do have a clearer picture of the context and only after understanding the qualitative work. The latter facilitates my understanding beyond what the numbers show”. (Erlyn Rachelle Macarayan, an Emerging Voice for Global Health [ http://www.ev4gh.net/] Philippines).

Participatory action research (PAR) is one form of qualitative research that has provided voice in research for marginalised groups and produced new evidence on risk-health patterning that has contributed to declines in work related ill-health and injuries [2729]. This approach has also contributed evidence on environmental determinants of health; barriers and enablers in managing ill health; and on learning about the roles and social relationships contributing to effective prevention and care [30].

In health service decision making, anthropological and qualitative studies have elucidated citizen responses to insurance, including why people enrol or drop out, and how families use health insurance [31, 32]. In relation to the Ebola crisis, this kind of research is particularly important to overcome implementation and coverage deficits, and to address the gap between policy intention and policy in practice [33, 34], to illuminate issues around trust and health service utilisation, and may contribute to building future health systems resilience [35].

The methodological diversity in qualitative research not only generates new evidence and knowledge for health systems policy, planning and practice, but also incorporates approaches to engage and participate with communities (and users of services) to utilise evidence and solutions to create change [30]. PAR and implementation research [30] embrace change through the co-creation of research with a range of stakeholders. For example, Othieno and colleagues [36] worked with women from low income communities in designing and implementing community mental health services [36]. Other examples of change and learning from change embedded within research, have been documented [30]. The methods systematize local experience and synthesize collective analysis on relationships and causes of problems.

The reflexive process is directly linked to new knowledge and action, influenced by understanding of history, culture, and local context and embedded in social relationships. In narrowly defining what research and thus what knowledge counts as important, the opportunity to learn from this richness is lost. Furthermore, this effectively silences the voices of community members, particularly those who are marginalised across all countries [3740].

Such research belongs in mainstream publication on health and should not simply be assigned to ‘special interest journals’. Doing so risks devaluing work relevant to health services, weakens understanding of the interface between qualitative and quantitative research and undermines the breadth and quality of analysis. Furthermore, the perception that such work will not be considered, even before peer review, has already resulted in some of our members sending manuscripts to special interest journals, and consequently having it hidden from a more general audience who might have benefitted from its insights.

The inadequate publication space for qualitative studies is a generalised problem that undermines our understanding of and response to health system challenges. Addressing it calls for specific strategies, such as establishing panels of suitable reviewers and enhancing the quality of guidelines for researchers and authors.

We have cited numerous examples of the contribution of qualitative research to health service decision-making. It is problematic to reinforce the dichotomy between qualitative and quantitative research. Qualitative studies provide evidence that informs health services decision making, deepens interpretation and understanding, and assists all to better deal with the complexity inherent in health problems and the search for their solutions. Qualitative insights will also assist in closing the policy-implementation gap. We look forward to further debate and publication, including in this journal, on approaches to overcoming barriers to publication of qualitative research on health policy and systems, for researchers and journals, to ensure that crucial domains of research and knowledge are not excluded from health systems policy and practice.

Signatories

Social science approaches for research and engagement in health policy & systems (SHaPeS) thematic working group of Health Systems Global,

Regional Network for Equity in Health in East and Southern Africa (EQUINET),

and Emerging Voices for Global Health.

Declarations

Authors’ contributions

This open letter has been conceptualised and drafted collectively by the signatories and co-signatories. It was prepared with input and review from many in SHaPeS and EQUINET. Karen Daniels and Rene Loewenson led the first drafts, with further extensive writing support from Anthony Zwi, Steph Topp, Asha George, Bruno Marchal, Kabir Sheikh, Sally Theobald, Natasha Howard, Moses Tetui, Emma Sacks, Ligia Paina, Simon Lewin, Devaki Nambiar and Gergana Koleva (in no particular order). The open letter has been read and approved by all co-signatories.

Competing interests

This letter has been written collectively and voluntarily, without funding support. We have read and understood the BioMed Central’s guidance on competing interests and declare no competing interests.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Health Systems Research Unit, South African Medical Research Council
(2)
Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town
(3)
Training and Research Support Centre, Regional Network for Equity in Health in East and Southern Africa (EQUINET)
(4)
School of Public Health, University of the Western Cape
(5)
Department of International Health, Johns Hopkins University School of Public Health
(6)
London School of Hygiene & Tropical Medicine
(7)
Patient Experience Researcher and Advocate for Patient and Public Involvement
(8)
Global Health Unit, Knowledge Centre for the Health Services, Norwegian Institute of Public Health
(9)
Department of Public Health, Institute of Tropical Medicine
(10)
Public Health Researcher
(11)
Department of International Health, Johns Hopkins School of Public Health
(12)
USAID Maternal and Child Survival Program (MCSP)/ICF International
(13)
Public Health Foundation of India
(14)
Makerere University School of Public Health
(15)
Umea International School Of Public Health, Umea University
(16)
Department of International Public Health, Liverpool School of Tropical Medicine
(17)
Institute of Development Studies
(18)
College of Public Health, Medical and Veterinary Science, James Cook University
(19)
Health Rights and Development, School of Social Sciences, The University of New South Wales

References

  1. Greenhalgh T, Annandale E, Ashcroft R, Barlow J, Black N, Bleakley A, Boaden R, Braithwaite J, Britten N, Carnevale F, et al. An open letter to The BMJ editors on qualitative research. BMJ. 2016;352:i563.View ArticlePubMedGoogle Scholar
  2. Shuval K, Harker K, Roudsari B, Groce NE, Mills B, Siddiqi Z, Shachak A. Is qualitative research second class science? A quantitative longitudinal examination of qualitative research in medical journals. PLoS One. 2011;6:e16937.View ArticlePubMedPubMed CentralGoogle Scholar
  3. The BMJ editors respond [http://www.bmj.com/content/352/bmj.i641/rr-13]. Accessed 7 Mar 2016.
  4. Loder E, Groves T, Schroter S, Merino JG, Weber W. Qualitative research and The BMJ. BMJ. 2016;352:i641.View ArticlePubMedGoogle Scholar
  5. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311:42–5.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323:625–8.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Wilson T, Holt T, Greenhalgh T. Complexity science: complexity and clinical care. BMJ. 2001;323:685–8.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Gilson L, Hanson K, Sheikh K, Agyepong IA, Ssengooba F, Bennett S. Building the field of health policy and systems research: social science matters. PLoS Med. 2011;8:e1001079.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, Aguiar C, Saraiva Coneglian F, Diniz AL, Tuncalp O, et al. The Mistreatment of Women during Childbirth in Health Facilities Globally: A Mixed-Methods Systematic Review. PLoS Med. 2015;12:e1001847. discussion e1001847.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Colvin CJ, de Heer J, Winterton L, Mellenkamp M, Glenton C, Noyes J, Lewin S, Rashidian A. A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery. 2013;29:1211–21.View ArticlePubMedGoogle Scholar
  11. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013;10:CD010414.Google Scholar
  12. Grady D. Report shows widespread mistreatment by health workers during childbirth. In New York Times. Manhattan, New York: The New York Times Company; 2015.Google Scholar
  13. Glenton C, Lewin S, Norris SL. Using evidence from qualitative research to develop WHO guidelines(Chapter 15). In: World Health Organization Handbook for Guideline Development. 2nd ed. Geneva: WHO; 2016.Google Scholar
  14. Lewin S, Glenton C, Munthe-Kaas H, Carlsen B, Colvin CJ, Gulmezoglu M, Noyes J, Booth A, Garside R, Rashidian A. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Med. 2015;12:e1001895.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med. 2000;51:1087–110.View ArticlePubMedGoogle Scholar
  16. Angel S, Frederiksen KN. Challenges in achieving patient participation: A review of how patient participation is addressed in empirical studies. Int J Nurs Stud. 2015;52:1525–38.View ArticlePubMedGoogle Scholar
  17. Axelsson R, Axelsson SB. Integration and collaboration in public health--a conceptual framework. Int J Health Plann Manage. 2006;21:75–88.View ArticlePubMedGoogle Scholar
  18. Charles C, DeMaio S. Lay participation in health care decision making: a conceptual framework. J Health Polit Policy Law. 1993;18:881–904.View ArticlePubMedGoogle Scholar
  19. Walker L, Gilson L. ‘We are bitter but we are satisfied’: nurses as street-level bureaucrats in South Africa. Soc Sci Med. 2004;59:1251–61.View ArticlePubMedGoogle Scholar
  20. Gilson L, Doherty J, Loewenson R, Francis V. Challenging Inequity through Health Systems Final Report Knowledge Network on Health Systems. Geneva: WHO Commission on the Social Determinants of Health; 2007.Google Scholar
  21. Feldhaus I, Silverman M, LeFevre AE, Mpembeni R, Mosha I, Chitama D, Mohan D, Chebet JJ, Urassa D, Kilewo C, et al. Equally able, but unequally accepted: Gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania. Int J Equity Health. 2015;14:70.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Kim J, Motsei M. “Women enjoy punishment”: attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Soc Sci Med. 2002;54:1243–54.View ArticlePubMedGoogle Scholar
  23. Daniels K, Clarke M, Ringsberg KC. Developing lay health worker policy in South Africa: a qualitative study. Health Res Policy Syst. 2012;10:8.View ArticlePubMedPubMed CentralGoogle Scholar
  24. Kok MC, Kea AZ, Datiko DG, Broerse JE, Dieleman M, Taegtmeyer M, Tulloch O. A qualitative assessment of health extension workers’ relationships with the community and health sector in Ethiopia: opportunities for enhancing maternal health performance. Hum Resour Health. 2015;13:80.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010;(3). Art. No.:CD004015. doi:10.1002/14651858.CD004015.pub3.
  26. Glenton C, Lewin S, Scheel IB. Still too little qualitative research to shed light on results from reviews of effectiveness trials: A case study of a Cochrane review on the use of lay health workers. Implement Sci. 2011;6:53.View ArticlePubMedPubMed CentralGoogle Scholar
  27. Belinguer G. Una Riforma per la Salute. Bari: De Donato; 1979.Google Scholar
  28. Laurell AC, Noriega M, Martínez S, Villegas J. Participatory research on workers health. Soc Sci Med. 1992;34:603–13.View ArticlePubMedGoogle Scholar
  29. Rosskam E G, B, Mateski, M, McCarthy, V, Siegrist, J, Smith S, Wege N, Zsoldos L, Marowsky I, Rodriguez GM, Williamson E, James S, Tyler J. Stressed and Fatigued on the Ground and in the Sky: Changes from 2000 – 2007 in civil aviation workers’ conditions of work: A global study of 116 countries in Africa, Asia/Pacific, Middle East, North America, Latin/South America, and Europe in the post – 9/11 era. UK: ITWF; 2009Google Scholar
  30. Loewenson R, Laurell AC, Hogstedt C, D’Ambruoso L, Shroff Z. Participatory action research in health systems: a methods reader. Harare: TARSC, AHPSR, WHO, EQUINET; 2014.Google Scholar
  31. Ahlin T, Nichter M, Pillai G. Health insurance in India: what do we know and why is ethnographic research needed. Anthropol Med. 2016;23:102–24.View ArticlePubMedGoogle Scholar
  32. Dao A, Nichter M. The social life of health insurance in low- to middle-income countries. An Anthropological Research Agenda. Med Anthropol Q. 2016;30(1):122-43. doi:10.1111/maq.12191. Epub 2015 Mar 27.
  33. Adongo PB, Tabong PT, Asampong E, Ansong J, Robalo M, Adanu RM. Beyond Knowledge and Awareness: Addressing Misconceptions in Ghana’s Preparation towards an Outbreak of Ebola Virus Disease. PLoS One. 2016;11:e0149627.View ArticlePubMedPubMed CentralGoogle Scholar
  34. Elston JW, Moosa AJ, Moses F, Walker G, Dotta N, Waldman RJ, Wright J: Impact of the Ebola outbreak on health systems and population health in Sierra Leone. J Public Health (Oxf) 2015 [Epub ahead of print]Google Scholar
  35. Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet. 2015;385:1910–2.View ArticlePubMedGoogle Scholar
  36. Othieno C, Kitazi N, Mburu J, Obondo A, Mathai M, Loewenson R. Use of participatory, action and research methods in enhancing awareness of mental disorders in Kariobangi, Kenya. Int Psychiatry. 2009;(1)6:18–20.Google Scholar
  37. Gender, rights, equity: Reflections from the Cape Town Health Systems Research Symposium [http://resyst.lshtm.ac.uk/news-and-blogs/gender-rights-equity-reflections-cape-town-health-systems-research-symposium]. Accessed 18 Mar 2016.
  38. Ten gender-related points to keep in mind when you are doing health systems research [http://healthsystemsglobal.org/blog/71/Ten-gender-related-points-to-keep-in-mind-when-you-are-doing-health-systems-research.html]. Accessed 18 Mar 2016.
  39. Oke M. Using narrative methods in crosscultural research with Mongolian and Australian women survivors of domestic violence. Qual Res J. 2008;8:2–19.View ArticleGoogle Scholar
  40. Catalani C, Minkler M. Photovoice: a review of the literature in health and public health. Health Educ Behav. 2010;37:424–51.View ArticlePubMedGoogle Scholar

Copyright

© Daniels and Loewenson. 2016

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