the qualitative research interview

8
The qualitative research interview Barbara DiCicco-Bloom & Benjamin F Crabtree BACKGROUND Interviews are among the most familiar strategies for collecting qualitative data. The different qualitative interviewing strategies in com- mon use emerged from diverse disciplinary perspec- tives resulting in a wide variation among interviewing approaches. Unlike the highly structured survey interviews and questionnaires used in epidemiology and most health services research, we examine less structured interview strategies in which the person interviewed is more a participant in meaning making than a conduit from which information is retrieved. PURPOSE In this article we briefly review the more common qualitative interview methods and then focus on the widely used individual face-to-face in-depth interview, which seeks to foster learning about individual experiences and perspectives on a given set of issues. We discuss methods for conducting in-depth interviews and consider relevant ethical issues with particular regard to the rights and protection of the participants. KEYWORDS interviews *methods; interpersonal relations; data collection; data interpretation, statistical; ethics, medical. Medical Education 2006; 40: 314–321 doi:10.1111/j.1365-2929.2006.02418.x INTRODUCTION The integration of qualitative research into clinical research in the 1970s and 1980s introduced many distinct formats of qualitative interviews that greatly expanded the process of data collection and the depth of information being gathered. This article explores qualitative interviews and emphasises the individual in-depth interview. Other manuscripts in this Medical Education series have highlighted other qualitative data collection techniques, including narratives 1 , participant observation 2,3 and focus groups. 4 While all interviews are used to get to know the interviewee better, the purpose of that knowing varies according to the research question and the disci- plinary perspective of the researcher. Thus, some research is designed to test a priori hypotheses, often using a very structured interviewing format in which the stimulus (questions) and analyses are standard- ised, while other research seeks to explore meaning and perceptions to gain a better understanding and or generate hypotheses. This latter research generally requires some form of qualitative inter- viewing which encourages the interviewee to share rich descriptions of phenomena while leaving the interpretation or analysis to the investigators. 5 The purpose of the qualitative research interview is to contribute to a body of knowledge that is conceptual and theoretical and is based on the meanings that life experiences hold for the interviewees. In this article we review different qualitative interview formats with a focus on the face-to-face, in-depth qualitative research interview and conclude with a discussion of related technical and ethical issues. OVERVIEW OF QUALITATIVE INTERVIEWS Qualitative interviews have been categorised in a variety of ways, with many contemporary texts loosely differentiating qualitative interviews as unstructured, semi-structured and structured. 6–8 We will focus on unstructured and semi-structured formats because structured interviews often produce quantitative data. While the distinction between unstructured and making sense of qualitative research Department of Family Medicine, University of Medicine and Dentistry at Robert Wood Johnson Medical School, Somerset, New Jersey, USA Correspondence: Barbara DiCicco-Bloom RN, PhD, Department of Family Medicine, Research Division, 1 World’s Fair Drive, Somerset, New Jersey 08873, USA. Tel: 00 1 732 743 3368; E-mail: [email protected] Ó Blackwell Publishing Ltd 2006. MEDICAL EDUCATION 2006; 40: 314–321 314

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Page 1: The Qualitative Research Interview

The qualitative research interviewBarbara DiCicco-Bloom & Benjamin F Crabtree

BACKGROUND Interviews are among the mostfamiliar strategies for collecting qualitative data. Thedifferent qualitative interviewing strategies in com-mon use emerged from diverse disciplinary perspec-tives resulting in a wide variation among interviewingapproaches. Unlike the highly structured surveyinterviews and questionnaires used in epidemiologyand most health services research, we examine lessstructured interview strategies in which the personinterviewed is more a participant in meaning makingthan a conduit from which information is retrieved.

PURPOSE In this article we briefly review themore common qualitative interview methods andthen focus on the widely used individual face-to-facein-depth interview, which seeks to foster learningabout individual experiences and perspectives on agiven set of issues. We discuss methods forconducting in-depth interviews and consider relevantethical issues with particular regard to the rights andprotection of the participants.

KEYWORDS interviews ⁄*methods;interpersonal relations; data collection;data interpretation, statistical; ethics, medical.

Medical Education 2006; 40: 314–321doi:10.1111/j.1365-2929.2006.02418.x

INTRODUCTION

The integration of qualitative research into clinicalresearch in the 1970s and 1980s introduced manydistinct formats of qualitative interviews that greatlyexpanded the process of data collection and the

depth of information being gathered. This articleexplores qualitative interviews and emphasises theindividual in-depth interview. Other manuscripts inthis Medical Education series have highlighted otherqualitative data collection techniques, includingnarratives1, participant observation2,3 and focusgroups.4

While all interviews are used to get to know theinterviewee better, the purpose of that knowing variesaccording to the research question and the disci-plinary perspective of the researcher. Thus, someresearch is designed to test a priori hypotheses, oftenusing a very structured interviewing format in whichthe stimulus (questions) and analyses are standard-ised, while other research seeks to explore meaningand perceptions to gain a better understandingand ⁄or generate hypotheses. This latter researchgenerally requires some form of qualitative inter-viewing which encourages the interviewee to sharerich descriptions of phenomena while leaving theinterpretation or analysis to the investigators.5 Thepurpose of the qualitative research interview is tocontribute to a body of knowledge that is conceptualand theoretical and is based on the meanings that lifeexperiences hold for the interviewees. In this articlewe review different qualitative interview formats witha focus on the face-to-face, in-depth qualitativeresearch interview and conclude with a discussion ofrelated technical and ethical issues.

OVERVIEW OF QUALITATIVEINTERVIEWS

Qualitative interviews have been categorised in avariety of ways, with many contemporary texts looselydifferentiating qualitative interviews as unstructured,semi-structured and structured.6–8 We will focus onunstructured and semi-structured formats becausestructured interviews often produce quantitative data.While the distinction between unstructured and

making sense of qualitative research

Department of Family Medicine, University of Medicine and Dentistryat Robert Wood Johnson Medical School, Somerset, New Jersey, USA

Correspondence: Barbara DiCicco-Bloom RN, PhD, Department of FamilyMedicine, Research Division, 1 World’s Fair Drive, Somerset, NewJersey 08873, USA. Tel: 00 1 732 743 3368; E-mail:[email protected]

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semi-structured interviews is helpful and will be usedin this manuscript, it should be recognised that thisdifferentiation is artificial and combines strategiesthat historically have emerged from very differentdisciplines and traditions. For example, earlypioneers of ethnography, such as BronislawMalinowski9 and Margaret Mead,10,11 only usedunstructured interviews with local key informants;they had never heard of focus groups or in-depthinterviews. Early versions of the individual in-depthinterview were the major source of data for earlyphenomenologists like Edmund Husserl12 and theChicago School sociologists,13 who were contempor-aries of Malinowski and Mead, while the focus groupdid not emerge as a distinct interviewing tool untilthe mid-1940s14 and was initially used primarily inmarketing research.

Unstructured interviews

No interview can truly be considered unstructured;however, some are relatively unstructured and aremore or less equivalent to guided conversations. Themost widely used unstructured interview origin-ates from the ethnographic tradition of anthro-pology.9–11,15–18 Ethnographers gather data throughparticipant observation and record field notes as theyobserve from the sidelines and ⁄or as they join in the

activities of those they are studying. During thisprocess the investigator identifies one or more �keyinformants� to interview on an ongoing basis andtakes jottings or short notes while observing andquestioning.15 Key informants are selected for theirknowledge and role in a setting and their willingnessand ability to serve as translators, teachers, mentorsand ⁄or commentators for the researcher.19 Theinterviewer elicits information about the meaning ofobserved behaviours, interactions, artefacts and ritu-als, with questions emerging over time as the inves-tigator learns about the setting. For example, Miller20

explored the experiences of two older doctors abouttheir implementation of a family medicine approachto patient care. Unstructured interviews and partici-pant observation field notes were the predominantdata collection strategies used to elicit insights intothe ways the doctors organised and managed patientencounters.

Semi-structured interviews

Whereas the unstructured interview is conducted inconjunction with the collection of observational data,semi-structured interviews are often the sole datasource for a qualitative research project21 and areusually scheduled in advance at a designated timeand location outside of everyday events. They aregenerally organised around a set of predeterminedopen-ended questions, with other questionsemerging from the dialogue between interviewerand interviewee ⁄ s. Semi-structured in-depthinterviews are the most widely used interviewingformat for qualitative research and can occur eitherwith an individual or in groups. Most commonly theyare only conducted once for an individual or groupand take between 30 minutes to several hours tocomplete.

The individual in-depth interview allows the inter-viewer to delve deeply into social and personalmatters, whereas the group interview allows inter-viewers to get a wider range of experience but,because of the public nature of the process, preventsdelving as deeply into the individual.22–24 Groupinterviews often take the form of focus groups, withmultiple participants sharing their knowledge orexperience about a specific subject.14,25–27 Each focusgroup represents a single entity within a sample ofgroups – it is not an interview with distinct individualsand is not a short cut for collecting data from severalindividuals at the same time.28 Data should alsoinclude observer descriptions of group dynamics26

and analyses should integrate the interactiondynamics within each group.28

Overview

What is already known on this subject

Interviews are a data collection strategy usedacross many disciplines.

What this study adds

In this manuscript we discuss different formatsof qualitative interviews with a focus on in-depth interviews. In-depth interviews can beused to understand complex social issues thatare relevant to health care settings.

Suggestions for further research

We conclude with a discussion of technicaland ethical issues that are essential for thoseconsidering participating in qualitative inter-view research, and which warrant furtherexamination.

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There are a number of other forms of semi-structuredinterviews that should be briefly acknowledged. The�life history� interview reveals personal biography andis a potentially powerful method for understandinganother’s life story.29,30 A more controlled semi-structured interview uses free listings to explore themeaning of terms and the rules governing them, suchas the meaning of barriers to self-care by persons withcomorbid chronic illnesses.31

Individual in-depth interviews

Individual in-depth interviews are widely used byhealth care researchers to co-create meaning withinterviewees by reconstructing perceptions of eventsand experiences related to health and health caredelivery. These interviews are able to inform a widerange of research questions: How is pain perceived bychronic care patients? What are the attitudes towarddrug use among individuals with high levels of chronicmorbidity? Why do general practitioners (GPs)prescribe antibiotics for upper respiratory infections?What are GPs’ attitudes towards diabetes and patientswith diabetes that impact on quality of care?

Whatever the focus of the study, the basic researchquestion needs to be sufficiently focused so that arelatively homogenous group will have sharedexperiences about the topic.32 The basic researchquestion may well serve as the first interview question,but between 5 and 10 more specific questions areusually developed to delve more deeply into differentaspects of the research issue. The iterative nature ofthe qualitative research process in which preliminarydata analysis coincides with data collection oftenresults in altering questions as the investigators learnmore about the subject. Questions that are noteffective at eliciting the necessary information can bedropped and new ones added. Furthermore, theinterviewer should be prepared to depart from theplanned itinerary during the interview becausedigressions can be very productive as they follow theinterviewee’s interest and knowledge.23

DEVELOPING RAPPORT

Unlike the unstructured interviews used in traditionalethnography where rapport is developed over time, itis necessary for the interviewer to rapidly develop apositive relationship during in-depth interviews. Theprocess of establishing rapport is an essential com-ponent of the interview and is described in the classicworks of Palmer33 and Douglas.34 Essentially, rapportinvolves trust and a respect for the interviewee and the

information he or she shares. It is also the means ofestablishing a safe and comfortable environment forsharing the interviewee’s personal experiences andattitudes as they actually occurred. It is through theconnection of many �truths� that interview researchcontributes to our knowledge of the meaning of thehuman experience.5 Stages of rapport between theinterviewer and the interviewee have been describedby Spradley35 and others24,32,36 and generally includeapprehension, exploration, co-operation and partici-pation.

The initial apprehension phase is characterised byuncertainty stemming from the strangeness of acontext in which the interviewer and interviewee arenew.During this phase the goal is to get the intervieweetalking. The first question should be broad and open-ended, should reflect thenature of the research andbenon-threatening. If necessary, this question can berepeated with some embellishment, giving the inter-viewee time to hear what is being asked and to thinkabout how to respond. As responses are given, theinterviewer can in turn respond with prompts thatrepeat the words used by the interviewee. This processsignals the need for further clarification withoutleading the interviewee. Questions that can be inter-preted as leading or that prompt the intervieweethrough the use of words other than those used by theinterviewee can result in misleading answers.5 Thefollowing excerpt from an interview with an immigrantAsian nurse as she describes her relationships withother nurses on her hospital floor is an example of aprobe in which the interviewer repeats the inter-viewee’s words in order to enrich the description whilenot leading the interviewee:37

Respondent: So the other nurses say that I amsomething like a blend.

Interviewer: �Blend�.

Respondent: Well yes. I am not black or white. I amsomehow in the middle, a mix of both.

Following the interviewee’s response, �a mix of both�,unplanned follow-up questions can be carefullyconsidered to continue the conversation. Whilespontaneous, these should be as non-directive aspossible. Thus, rather than asking, �Didn�t that makeyou feel strange?’ the interviewer can ask, �How didthat make you feel?� Rather than assuming theinterviewee felt a certain way, the second questionencourages the interviewee to think about and shareher own feelings.5 Throughout the interview, the goalof the interviewer is to encourage the interviewee to

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share as much information as possible, unselfcon-sciously and in his or her own words.23

The exploration phase is when the intervieweebecomes engaged in an in-depth description. Thisprocess is accompanied by learning, listening, testingand a sense of bonding and sharing. The next phase,the co-operative phase, is characterised by a comfortlevel in which the participants are not afraid ofoffending one another and find satisfaction in theinterview process. The interviewer may take theopportunity to clarify certain points and the inter-viewee may correct the interviewer as they both makesense together of the interviewee’s world. This mayalso be a time to ask questions that were too sensitive toask at the beginning. If the interview process continuesfor a long time or if the interviewer and intervieweedevelop rapport rapidly, the participation stage mayoccur within the time limit of the in-depth interview.This stage of the process reflects the greatest degree ofrapport and at this point the interviewee takes on therole of guiding and teaching the interviewer.

SELECTING INTERVIEWEES

In-depth interviews are used to discover sharedunderstandings of a particular group. The sample ofinterviewees should be fairly homogenous and sharecritical similarities related to the research question.38

Selecting in-depth interview participants is based onan iterative process referred to as purposeful samp-ling that seeks to maximise the depth and richness ofthe data to address the research question.39 Forexample, Adams et al.21 used in-depth interviewsabout perceptions of caring for elderly patients withprimary care doctors to explore reasons why doctorslimit the number of elderly people for whom theyprovide care. Participants included both family doc-tors and general internists, with investigators max-imising the potential richness of the data throughmaximum variation sampling regarding age, genderand specialty training.39–41 The data were furtherenriched by carrying out some interviews, performingpreliminary analyses, and then selecting morerespondents to fill in emerging questions.

THE INTERVIEW PROCESS

The in-depth interview is meant to be a personal andintimate encounter in which open, direct, verbalquestions are used to elicit detailed narratives andstories. Traditionally the structure of the in-depthinterview dictates that the interviewer maintains

control over the interaction with the interviewee’sco-operation.36 Accordingly, the roles assigned by theinterview structure pre-empt the roles the interviewerand interviewee have in their social worlds outsidethe interview event.

Another view of the in-depth interview processpromoted by feminist researchers maintains that byattempting to control for the social roles of theinterviewer and the interviewee ⁄ s, the research pro-cess is oppressive, as if the life of the interviewee is�just there� waiting to be described.42 Ignoring socialdifferences neglects the fact that the respective socialroles always shape the interview process and that theact of interviewing is invasive. For this reason,reflexivity on the part of the researcher is essential. Inthis process, the researcher gives thought to his orher own social role and that of the interviewee,acknowledging power differentials between them andintegrating reciprocity into the creation of know-ledge.43 For example, Anderson interviewed Chineseand Anglo-Canadian women with diabetes abouttheir health and illness experiences.44 The partici-pants asked her for clinical information aboutdiabetes based on their knowledge of her social roleas a nurse. The realities of the participants’ livescoupled with their requests for help was addressedthrough a reciprocal process. The investigatorobtained information from the participants and atthe same time provided them with information.

It could be argued that by acting both as a nurse andan investigator, Anderson’s capacity to remainobjective was compromised. It could also be arguedthat the goal of finding out about people andestablishing trust is best achieved by reducing thehierarchy between informants and researchers, whichin this case involved sharing information in responseto the informants’ requests. Some research approa-ches, such as participatory action research45 andfeminist methodologies,42,46 highlight the import-ance of reciprocation with informants in response tothe time, energy and information they contribute tothe research enterprise.

DATA ANALYSIS

Qualitative data analysis ideally occurs concurrentlywith data collection so that investigators can generatean emerging understanding about research ques-tions, which in turn informs both the sampling andthe questions being asked. This iterative process ofdata collection and analysis eventually leads to apoint in the data collection where no new categories

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or themes emerge. This is referred to as saturation,signalling that data collection is complete.39 Due tospace limitations we are only able to introduce thebroad categories of approaches used for analysis andwould recommend that readers refer to texts descri-bing qualitative data analysis such as Denzin andLincoln,47 Creswell,40 Crabtree and Miller,7 Miles andHuberman48 and Silverman.49

Briefly, just as the various forms of qualitativeinterviews emerged from diverse disciplines anddisciplinary traditions, analysis strategies alsoemerged from these different precursors. Some ofthese analytic strategies have been widely used forinterpreting in-depth interviews, particularly thegrounded theory approach that emerged in sociologyin the 1960s50 and a similar hermeneutic approachthat emerged from early philosophy.51,52 This strat-egy has been referred to as an �editing approach�because the investigators review and identify textsegments much as an editor does while makinginterpretative statements during the process of iden-tifying patterns for organising text.53,54 A commonlyused approach relies on using codes from a code-book for tagging segments of text and then sortingtext segments with similar content into separatecategories for a final distillation into majorthemes.48,49 This approach has been described as a�template approach� as it involves applying a template(categories) based on prior research and theoreticalperspectives.53,54 A team from Ontario, Canada usedthis strategy to apply more than 100 codes in a studyto understand the smoking experience and cessationprocess.55 Finally, if one reviews the analytic strategiesof early ethnographers, it is possible to discern amuch less structured approach in which the analystrepeatedly immerses him or herself into the text inreflective cycles until interpretations intuitively crys-tallise.56 This �immersion ⁄ crystallisation� approachrequires a strong theoretical background and con-siderable experience so would not be recommendedfor those new to qualitative research.

TECHNICAL ISSUES

In this section we briefly review:

1 processes for recording interview data;2 transcribing data, and3 using software programs to assist with data man-

agement and analysis.

Methods for recording interviews for documentationand later analysis include audiotape recording,

videotape recording and note taking.23,24,57 The mostcommon way to record interviews is with a tape-recorder. Maintaining high quality tape-recordingscan prevent difficulties later in the research process.Excessive background noise, weak batteries, place-ment of the recorder and other issues are all factorsinfluencing the quality of recorded interviews. Somenewer digital recorders are very effective, but can alsobe complicated to use. Thus, practising with arecorder prior to using it in a research study isessential. Having extra batteries and a back-up recor-der on hand are highly recommended. Most institu-tional ethics committees require that a specificconsent for tape-recording be included in informedconsent forms that must be signed prior to aninterview. This recognises that tape-recorded data canbe a source of danger for those who are taped becauserecorded data is incontrovertible. Recorded datashould be carefully guarded and generally destroyedafter transcription or once analysis is complete.

Transcribing tape-recorded interviews into text is aprocess that remains relatively unexplored. Polanddiscusses at length some of the issues that can interferewith the accuracy of transcribed data.58 Transcribersoften have difficulties capturing the spoken word intext form because of sentence structure, use ofquotations, omissions and mistaking words or phrasesfor others.59 Because people often speak in run-onsentences, transcribers are forced to make judgementcalls. The insertion of a period or a comma can changethe meaning of an entire sentence. When workingwith audio data, most experienced researchers listento the audiotape while reading the transcriptions toensure accuracy during interpretation. This issue iscomplicated and deserves further exploration if tran-scriptions are to be used.60

Computer-assisted qualitative data analysis software isa relatively recent development and follows theproliferation of personal computers since the early1980s. From early pioneering software, such as TheEthnograph,61 has emerged very sophisticated pro-grams like Atlas ti,62 Folio Views59 and NVivo.59 Atlasti even offers the intriguing potential of codinguntranscribed digital segments of interviews. Tesch63

noted 15 years ago that using a computer to facilitateanalysis can save time, make procedures moresystematic, reinforce completeness and permit flexi-bility with revision of analysis processes. Althoughusers of software keep requesting new and moresophisticated data analysis programs, the experience,discipline and expertise of research teams remain theessential ingredients for excellence in qualitativeresearch analysis. Software programs do not analyse

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data but they can be a tremendous aid in datamanagement and the analysis process.

ETHICAL ISSUES

We consider four ethical issues related to the inter-view process:

1 reducing the risk of unanticipated harm;2 protecting the interviewee’s information;3 effectively informing interviewees about the nat-

ure of the study, and4 reducing the risk of exploitation.

The interviewer’s task is to obtain information whilelistening and encouraging another person to speak.One of the dangers of interviewing from the per-spective of the interviewee is the act of listeningitself.64 When the interviewer listens and reflectspersonal information back to the interviewee, theprocess may develop in unforeseen ways. This canresult in unintended harm to the respondent. Forexample, during research involving in-depth inter-views with nurses from India who had been workingin the USA for 10–25 years, all the participants werecarefully informed about the nature of the study andsigned explicit consent forms.37 Despite this, severalunexpectedly expressed grief and intense feelingswhen talking about their lives. In a few cases thenurses shared that they had never discussed theirgrief previously. It became evident that many partic-ipants had not fully processed their separation fromtheir homeland and families of origin. It was fortu-itous for the investigator that all the participantsexpressed relief and comfort upon completion of theinterviews for having had the opportunity to sharetheir stories. That said, this experience could haveresulted in unintended harm to participants. There-fore, investigators must be prepared to providepsychological support if their interviews create unduestress or raise psychological complications.

The second issue is that the anonymity of theinterviewee in relation to the information sharedmust be maintained. During interviewing, the inter-viewee may share information that could jeopardisehis or her position in a system. This information mustremain anonymous and protected from those whoseinterests conflict with those of the interviewee. Forexample, in a study of primary care practices,interviewees often have positions at the lower end ofthe occupational hierarchy. Interviews may result inopportunities for individuals to vent their frustrationsand share their experiences. Although the work

environment might improve if concerns were madeknown, interviewee anonymity is to be protected firstand foremost unless the failure to share the infor-mation creates a dangerous situation.

The third ethical issue concerns ensuring adequatecommunication of the intent of the investigation. Thisis complicated by the fact that the investigator may notinitially know what data he or she will uncover andtherefore the purposes that may emerge from theprocess. It is therefore recommended that intervieweesverbally consent to participate in on-going interviewsseveral times during the research process.65 Partici-pants have the right to disengage from a research studyat any time. By asking for consent to participate severaltimes during the course of a study, this actuality isreinforced and provides the opportunity for inter-viewees to reconsider their participation.40

Lastly, interviewees should not be exploited forpersonal gain. It is important to build into theresearch plan a method of acknowledging the con-tributions that respondents make to the success ofthe research process and to �reimburse� them invarious ways for their efforts.44

Klockars66 suggests that the measure of the ethicalquality of any interview study is whether or not theresearcher suffers with the participants. Reiman67

further suggests that the outcome of interviewresearch should enhance the freedom of the partic-ipants more than it enhances the author’s career. Weconclude this section with a thought about thepersonal and intimate nature of interview data andthe potential for unanticipated experiences that canand perhaps should evoke ongoing concern. It is theview of the authors that the standard ethical practicesthat guide qualitative interview research represent awork in process. We encourage those who engage inqualitative interview research to view these standardsas a stepping off point. Interview researchers need toconsider the implications of their own research anduse their experiences as a guide to enhance their ownethical standards as well as those that apply tointerview research as a whole.

CONCLUSIONS

In-depth interviews can provide rich and in-depthinformation about the experiences of individuals;however, there are many different forms ofqualitative research interviews as well as other types ofqualitative research methods that can be used byhealth care investigators. These diverse forms of

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qualitative research are covered in other issues of thisjournal and celebrated in the latest edition of theHandbook of Qualitative Research.47

It must also be recognised that many clinical questionsare complex and investigators should perform athoughtful analysis of all the possiblemethods that canbe used to answer a research question.54 Increasingly,mixed methods in which both qualitative and quanti-tative approaches are integrated are needed to con-tribute to a rich and comprehensive study.68,69 Mixedmethods can provide potentially rigorous and meth-odologically sound study designs in primary care, withqualitative approaches such as interviews being anintegral component of an evolving study process that isresponsive to emerging insights.

Contributors: both authors contributed to theconception, design and intellectual content of thismanuscript, and drafted, revised and gave final approval ofthe manuscript.Acknowledgements: none.

Funding: this research was funded by the Bureau ofHealth Professions (HRSA), Academic Administrative Unitsin Primary Care (1D12HP00167).Conflicts of interest: none.

Ethical approval: not required.

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Received 4 November 2004; editorial comments to authors25 January 2005, 24 May 2005, 19 September 2005;accepted for publication 16 November 2005

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