“Was it something I said?” Why psychological research needs qualitative data


 

Psychology: the science of human behaviour. The hallmarks of sound Science are rigour, objectivity, and systematic study. A science is only as objective as the subject matter it studies. Then comes the contradiction: humans are complex and unpredictable. We are not objective subject matter, we are the antithesis; subjective.

I am not a number! I am a free man!

Perhaps we should stop attempting to objectify the subjective and, instead, embrace what makes this science unique from all others. We can embrace this subjectivity by applying qualitative analyses to the study of humans. That is not to suggest abandonment of quantitative analyses. Even a subjective science needs numbers. But we have more substance than numbers suggest, and the reductionism inherent in quantitative data, when humans are the focal point of the study, leads to an unfortunate waste of rich, insightful data. This gold dust serves to enlighten; explaining and illuminating the numbers. It compliments the numbers we produce through quantitative psychological research.

Why does psychological research need qualitative data?
Qualitative data is concerned with the how and why; it taps into the psychological processes that individuals engage in. Qualitative methodologies provide insight into how things occur, how we make sense of our surroundings and how we arrive at the decisions we ultimately make. In contrast to much quantitative research, qualitative designs allow researchers to investigate issues within a real-world context, rather than the controlled environment created by quantitative surveys which aim to yield only numbers. A paper critically appraising the use of qualitative research wrote that, “qualitative research aims to generate in-depth accounts from individuals and groups by talking with them, watching their behaviour, analysing their artefacts and taking into account the different contexts in which they are based.”1

“It’s ability to refine or criticise existing theories and provide us with rich descriptions to enhance our understanding of a certain process or phenomenon makes qualitative research increasingly important in healthcare today” – Dr Lorelei Lingard, Professor in the Department of Medicine at the University of Western Ontario.2

Healthcare research has found itself to be driven by the paradigm of quantitative research. This indicates missed opportunities to investigate the richer descriptions of phenomena which would allow us greater insight into human processes. A prime example of where qualitative research proves its greater utility is the pertinent issue of patients’ non-adherence to medications. Prevalence rates of non-adherence, yielded through quantitative designs, is undeniably essential to our understanding of the gravity of the issue. However, tapping into the thought processes underpinning the issue is essential. We cannot begin to transform non-adherence and create interventions to target this issue if we do not first obtain insights into the processes operating at its core. We do not dispute the continued use of quantitative research methods, but instead advocate the integration of qualitative methods into current designs; creating hybrid research designs that yield the best of both.

 

References

1. Kuper, A., Lingard, L., & Levinson, W. (2008). Critically appraising qualitative research. Bmj, 337
2. The importance of qualitative research in healthcare https://www.singhealth.com.sg/TomorrowsMed/Article/Pages/TheImportanceofQualitativeResearchinHealthcare.aspx


Beyond Nudge


Thaler’s pop science hit book Nudge1 has certainly created a stir; bringing behavioural science to the centre stage in the policymaking, private, and public arenas. The knock-on effect has been a growing excitement about the behavioural science buzz and the society-wide innovations such a ‘liberal paternalistic’ approach can offer.

In our day to day lives we make countless decisions. Many without paying much thought; and many despite often knowing they are not in our overall best long-term interests. In this sense, we are not making decisions to optimise our health and happiness in the way a completely rational being should. The concept of a ‘nudge’ acknowledges this and builds factors into our environment that makes it easier for us to make decisions that are better aligned with our long-term interests.

A good example of this is ‘opt-in’ automatic enrolment forms. Decisions, such as setting up a pension can seem cognitively draining, confusing and involve complex decisions about options we do not fully understand. Without a highly urgent motivation, the lack of ease is a barrier to action. However, automatic enrolment makes it cognitively and physically easier to make a decision for the best outcome – and increases saving.

However, much of our understanding of nudges comes from studies using simple laboratory-based tasks and we must always be cautious when extrapolating these to more complex real life situations; not all behaviours have been subject to simple effective modification by nudges alone. For example, it would be ludicrous to expect a nudge technique to persuade a patient with a peanut allergy to consume a pack of nuts. Medicines taking behaviours are another prime example of this. Many approaches to increase adherence in recent years have focused on removing practical barriers to medicines taking and providing simple nudges to make it easier to adhere. These engineer an environment for the patient whereby taking the medicine becomes easier – it involves less physical and cognitive strain. An example of this could be a pill reminder, informing the patient when to take their medicine. However, recent reports have suggested such approaches may have limited impact and do not increase adherence in all cases.2

Decisions patients make about medicines taking, like all decisions come down to two reasons – they can’t and don’t want to. Can’t: the action is not easy to make and don’t want to: their beliefs are leading them to choose not to. (Referring back to the patient with a peanut allergy, they may be perfectly capable of assembling and eating a peanut butter and jam sandwich, but regardless, do not want to.) This is outlined in the Perceptions and Practicalities Approach3 (PAPA™), which informs the NICE guidelines on adherence.4 This explains decisions as an interplay between intentional and non-intentional factors. Nudges typically remove practical barriers and making the optimal decision ‘easier’, when motivation to overcome practical barriers would otherwise not be sufficiently high. This is demonstrated in Figure 1a.

However, in cases where the non-adherence is intentional, there is motivation driving against adherence due to patients’ perceptions. Nudges will not address these perceptual factors and thus are less likely to be effective. The motivational drivers of the patients’ intention against adherence must also be addressed. (See Figure 1c.)

So how can we address the motivational drivers of intentional non-adherence? Studies analysing the patients’ perceptions of their disease and treatment are highly informative here. Patient perceptions, including those that they may not be extrinsically aware of, are accurate at predicting medicines taking behaviours. These perceptions can be understood as a trade-off between necessity beliefs and concerns. This has been shown, through a meta-analysis of over 25,000 patients covering 24 conditions in 18 countries, to be the most significant predictor of adherence.5

Patients can be individually mapped according to their level of necessity beliefs and concerns, as shown in Figure 2. Patients who have high concerns, but low necessity beliefs are sceptical, so have motivation not to adhere, whereas those with high necessity beliefs and lower concerns are accepting of their medicine. These patients have a greater positive motivation and are more likely to adhere.6 Increasing motivation for adherence requires either increasing patients’ necessity beliefs, or decreasing their concerns. That is, shifting patients towards the bottom right quadrant of the map.

An optimal approach to increase adherence must address the underlying perceptions that underpin a patients’ motivations and intentions to adhere, as well as making it easy to do. Therefore, in order for a nudge to be effective, perceptual barriers that relate to intentional must first be addressed.

Figure 1. Impact of nudges on adherence. (a) When patients have low motivation to adhere and not adhere, adherence may be low if not made easy to achieve. A nudge can increase adherence by making it easier. (b) When patients have high necessity beliefs they are more likely to be adherent, so the impact of a nudge on increasing adherence may be small. (c) Patients have greater concerns than necessity beliefs and are likely to be non-adherent. Nudges that make adherence seem cognitively and practically easier are unlikely to be effective if the concerns are not addressed.

Figure 2. Necessity beliefs and concerns perceptual map. Patients with greater necessity and lower concerns are most likely to be adherent.

References

1. Thaler RH, Sunstein CR. Nudge: Improving Decisions about Health, Wealth, and Happiness. Yale University Press; 2008.

2. Slomski A. Pill Reminders Don’t Improve Adherence. JAMA. 2017;317(24):2476. doi:10.1001/jama.2017.7588

3. Chapman SCE, Horne R, Eade R, Balestrini S, Rush J, Sisodiya SM. Applying a perceptions and practicalities approach to understanding nonadherence to antiepileptic drugs. Epilepsia. 2015;56(9):1398-1407. doi:10.1111/epi.13097

4. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence | Guidance and guidelines | NICE. https://www.nice.org.uk/guidance/cg76. Accessed June 27, 2017.

5. Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding Patients’ Adherence-Related Beliefs about Medicines Prescribed for Long-Term Conditions: A Meta-Analytic Review of the Necessity-Concerns Framework. PLOS ONE. 2013;8(12):e80633. doi:10.1371/journal.pone.0080633

6. Mann DM, Ponieman D, Leventhal H, Halm EA. Predictors of adherence to diabetes medications: the role of disease and medication beliefs. J Behav Med. 2009;32(3):278-284. doi:10.1007/s10865-009-9202-y


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