Basics of qualitative research: Grounded theory procedures and techniques

The aim of interpretative phenomenological analysis (IPA) is to explore in detail how participants are making sense of their personal and social world, and the main currency for an IPA study is the meanings particular experiences, events, states hold for participants. The approach is phenomenological (see Chapter 3) in that it involves detailed examination of the participant’s lifeworld; it attempts to explore personal experience and is concerned with an individual’s personal perception or account of an object or event, as opposed to an attempt to produce an objective statement of the object or event itself. At the same time, IPA also emphasizes that the research exercise is a dynamic process with an active role for the researcher in that process. One is trying to get close to the participant’s personal world, to take, in Conrad’s (1987) words, an ‘insider’s perspective’, but one cannot do this directly or completely. Access depends on, and is complicated by, the researcher’s own conceptions; indeed, these are required in order to make sense of that other personal world through a process of interpretative activity. Thus, a two-stage interpretation process, or a double hermeneutic, is involved. The participants are trying to make sense of their world; the researcher is trying to make sense of the participants trying to make sense of their world. IPA is therefore intellectually connected to hermeneutics and theories of interpretation (Packer and Addison, 1989; Palmer, 1969; Smith, in press; see also Chapter 2 this volume). Different interpretative stances are possible, and IPA combines an empathic hermeneutics with a questioning hermeneutics. Thus, consistent with its phenomenological origins, IPA is concerned with trying to understand what it is like, from the point of view of the participants, to take their side. At the same time, a detailed IPA analysis can also involve asking critical questions of the texts from participants, such as the following: What is the person trying to achieve here? Is something leaking out here that wasn’t intended? Do I have a sense of something going on here that maybe the participants themselves are less aware of?

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Interpretative Phenomenological Analysis

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

https://link.springer.com/content/pdf/10.1007%2Fs11135-017-0574-8.pdf

Saturation in qualitative research: exploring its conceptualization and operationalization

Patients with chronic conditions make day-to-day decisions about—selfmanage—their illnesses. This reality introduces a new chronic disease paradigm: the patient-professional partnership, involving collaborative care and self-management education. Self-management education complements traditional patient education in supporting patients to live the best possible quality of life with their chronic condition. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is selfefficacy—confidence to carry out a behavior necessary to reach a desired goal. Self-efficacy is enhanced when patients succeed in solving patientidentified problems. Evidence from controlled clinical trials suggests that (1) programs teaching self-management skills are more effective than informationonly patient education in improving clinical outcomes; (2) in some circumstances, self-management education improves outcomes and can reduce costs for arthritis and probably for adult asthma patients; and (3) in initial studies, a self-management education program bringing together patients with a variety of chronic conditions may improve outcomes and reduce costs. Selfmanagement education for chronic illness may soon become an integral part of high-quality primary care.

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Patient Self-management of Chronic Disease in Primary Care

Self-management approaches for people with chronic conditions: a review.

Increasing self-efficacy is generally considered to be an important mediator of the effects of physical activity interventions. A previous review identified which behaviour change techniques (BCTs) were associated with increases in self-efficacy and physical activity for healthy non-obese adults. The aim of the current review was to identify which BCTs increase the self-efficacy and physical activity behaviour of obese adults. A systematic search identified 61 comparisons with obese adults reporting changes in self-efficacy towards engaging in physical activity following interventions. Of those comparisons, 42 also reported changes in physical activity behaviour. All intervention descriptions were coded using Michie et al’s (2011) 40 item CALO-RE taxonomy of BCTs. Meta-analysis was conducted with moderator analyses to examine the association between whether or not each BCT was included in interventions, and size of changes in both self-efficacy and physical activity behaviour. Overall, a small effect of the interventions was found on self-efficacy (d = 0.23, 95% confidence interval (CI): 0.16-0.29, p < 0.001) and a medium sized effect on physical activity behaviour (d = 0.50, 95% CI 0.38-0.63, p < 0.001). Four BCTs were significantly associated with positive changes in self-efficacy; ‘action planning’, ‘time management’, ‘prompt self-monitoring of behavioural outcome’ and ‘plan social support/social change’. These latter two BCTs were also associated with positive changes in physical activity. An additional 19 BCTs were associated with positive changes in physical activity. The largest effects for physical activity were found where interventions contained ‘teach to use prompts/cues’, ‘prompt practice’ or ‘prompt rewards contingent on effort or progress towards behaviour’. Overall, a non-significant relationship was found between change in self-efficacy and change in physical activity (Spearman’s Rho = −0.18 p = 0.72). In summary, the majority of techniques increased physical activity behaviour, without having discernible effects on self-efficacy. Only two BCTs were associated with positive changes in both physical activity self-efficacy and behaviour. This is in contrast to the earlier review which found a strong relationship between changes in physical activity self-efficacy and behaviour. Mechanisms other than self-efficacy may be more important for increasing the physical activity of obese individuals compared with non-obese individuals.

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What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis

The objective of this study was to determine whether the Arthritis Self-Management Programme (ASMP) improves perceptions of control, health behaviours and health status, and changes use of health care resources. The design was a pragmatic randomized controlled study; participants were allocated to ASMP (Intervention Group) or a 4-month waiting-list Control Group. The Intervention Group completed a 12-month follow-up. In total, 544 people with arthritis were recruited from the community--311 in the Intervention Group and 233 in the Control Group. Main outcome measures included: arthritis self-efficacy, health behaviours (exercise, cognitive symptom management, diet and relaxation) and health status (pain, fatigue, anxiety, depression and positive affect). At 4 months follow-up, the ASMP had a significant effect on arthritis self-efficacy for other symptoms and pain subscales. Performance of a range of health behaviours (cognitive symptom management, communication with physicians, dietary habit, exercise and relaxation) was significantly greater among the Intervention Group. The Intervention Group were significantly less depressed and had greater positive mood. In addition, trends towards decreases on fatigue and anxiety were noted. Physical functioning, pain and GP visits remained stable at 4 months. A similar pattern of findings was found at 12 months follow-up for the Intervention Group. Furthermore, a significant improvement was found on pain and visits to GPs had decreased. Apart from a small improvement on physical functioning among the Intervention Group participants with osteoarthritis 12 months, all effects were independent of the type of arthritis. The findings suggest that the ASMP is effective in promoting improvements in perception of control, health behaviours and health status, when delivered in UK settings.

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A randomized controlled study of the Arthritis Self-Management Programme in the UK

Background Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge. Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally–led programmes. We report the first randomised trial of a lay-led self-management programme — the Chronic Disease Self-Management Programme (CDSMP) (Expert Patient Programme) — in a south Asian group. Aim To determine the effectiveness of a culturally-adapted lay–led self-management programme for Bangladeshi adults with chronic disease. Design of study Randomised controlled trial. Setting Tower Hamlets, east London. Method We recruited Bangladeshi adults with diabetes, cardiovascular disease, respiratory disease or arthritis from general practices and randomised them to the CDSMP or waiting-list control. Self-efficacy (primary outcome), self-management behaviour, communication with clinician, depression scores, and healthcare use were assessed by blinded interviewer-administered questionnaires in Sylheti before randomisation and 4 months later. Results Of the 1363 people invited, 476 (34%) agreed to take part and 92% (439/476) of participants were followed up. The programme improved self-efficacy (difference: 0.67, 95% confidence interval [CI] = 0.08 to 1.25) and self-management behaviour (0.53; 95% CI = 0.01 to 1.06). In the 51% (121/238) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy (1.47; 95% CI = 0.50 to 1.82) and self-management behaviour (1.16; 95% CI = 0.50 to 1.82), and reduced HADS depression scores (0.64; 95% CI = 0.07 to 1.22). Communication and healthcare use were not significantly different between groups. The programme cost £123 (€181) per participant. Conclusion A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease. Effects on health status were marginal. Benefits were limited by moderate uptake and attendance.

Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease

Walking groups are increasingly being set up but little is known about their efficacy in promoting physical activity. The present study aims to assess the efficacy of interventions to promote walking in groups to promoting physical activity within adults, and to explore potential moderators of this efficacy. Systematic literature review searches were conducted using multiple databases. A random effect model was used for the meta-analysis, with sensitivity analysis. The effect of the interventions (19 studies, 4 572 participants) on physical activity was of medium size (d = 0.52), statistically significant (95%CI 0.32 to 0.71, p < 0.0001), and with large fail-safe of N = 753. Moderator analyses showed that lower quality studies had larger effect sizes than higher quality studies, studies reporting outcomes over six months had larger effect sizes than studies reporting outcomes up to six months, studies that targeted both genders had higher effect sizes than studies that targeted only women, studies that targeted older adults had larger effect sizes than studies that targeted younger adults. No significant differences were found between studies delivered by professionals and those delivered by lay people. Interventions to promote walking in groups are efficacious at increasing physical activity. Despite low homogeneity of results, and limitations (e.g. small number of studies using objective measures of physical activity, publication bias), which might have influence the findings, the large fail-safe N suggests these findings are robust. Possible explanations for heterogeneity between studies are discussed, and the need for more investigation of this is highlighted.

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Andy Turner

Papers

Self-management approaches for people with chronic conditions: a review.

What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis

A randomized controlled study of the Arthritis Self-Management Programme in the UK

Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease

Do interventions to promote walking in groups increase physical activity? A meta-analysis