Patient Education and Counseling 82 (2011) 384–388

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Qualitative research on health communication: What can it contribute?

Nicky Britten *
Peninsula Medical School, University of Exeter, Exeter, UK

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To contribute to the debate about the value of qualitative research in health care by discussing
Received 18 August 2010 three key issues in relation to qualitative research on health communication.
Received in revised form 10 December 2010 Methods: As this paper does not report the results of a primary research study or a secondary analysis, no
Accepted 17 December 2010
formal search strategy was employed to identify the cited papers; many other published papers would
have made the same points just as well.
Keywords: Results: The key issues are illustrated using a range of published studies drawn from the health care
Qualitative research
communication literature. The paper describes the range of outputs generated by qualitative research;
Synthesis
Description
illustrates different ways in which qualitative and quantitative methods can be combined; and shows
Explanation the contribution of qualitative syntheses.
Conclusions: Greater conceptual development and explanatory power may be achieved both by more
ambitious primary studies and the conduct of more qualitative syntheses. The synthesis of qualitative
research also offers the opportunity to build up a cumulative evidence base.
Practice implications: The further development of methods of qualitative synthesis will be enhanced if
qualitative researchers place greater emphasis on explanation rather than description; cite each other’s
work more often and conduct more syntheses; and continue to contribute to mixed methods studies.
! 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction questions which matter. My purpose in this article is to contribute

Although the status and acceptability of qualitative research
within medical and health services research has changed to an
astonishing degree, there remains a debate about its value in
health research. Critics are less likely (in public at least) to dismiss
qualitative research as ‘anecdotal’ and ‘unscientific’ [1]. Increas-
ingly, randomised controlled trials include qualitative process
evaluations [2], funding bodies include qualitative researchers on
grant giving committees, and researchers discuss questions about
quality appraisal in qualitative research. All this was unimaginable
in the early 1990s [3]. However medical research places
quantitative evidence much higher up the hierarchy of evidence
than qualitative research [4]; this is because questions about the
effectiveness of an intervention or treatment are much better
addressed by quantitative methods. Within communication
research, quantitative measures such as the Roter Interaction
Analysis System [5] and the OPTION scale [6] are better established
and more widely used than qualitative methods. These measures
enable statistical methods to be employed, and quantitative
questions to be answered. However, these are not the only
to the debate by showing that qualitative research can make
particular kinds of contribution to health communication research.
These contributions are illustrated by examining the outputs of
qualitative research; the combination of qualitative and quantita-
tive research; and the synthesis of qualitative research.
2. Methods
This is a debate paper which aims to demonstrate the
contribution which qualitative research can make to health
communication research. In doing so, it adds to the long standing
debate about the value of qualitative research [7]. All the
references to published studies are for illustrative purposes, and
have been chosen on the basis of the author’s prior knowledge and
the relevance of the papers to this audience of readers. This paper
does not report the results of either primary qualitative research,
or the synthesis of qualitative research, and thus no formal search
strategy was employed to identify the cited papers. Many other
published papers would have made the same points just as well.
3. Results

3.1. Basic introduction into qualitative research

* Correspondence address: Institute of Health Service Research, Peninsula
Medical School, University of Exeter, Veysey Building, Salmon Pool Lane, Exeter,
Devon EX2 4SG, Exeter, UK. Tel.: +44 1392 724859; fax: +44 1392 421009. Given that the term ‘qualitative research’ is not always used
E-mail address: nicky.britten@pms.ac.uk. consistently, it is worth starting with a definition. Green and

0738-3991/$ – see front matter ! 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.12.021
 N. Britten / Patient Education and Counseling 82 (2011) 384–388
Thorogood [8] point out that qualitative studies seek answers to
questions about the ‘what’, ‘how’ or ‘why’ of a phenomenon rather
than questions about ‘how many’ or ‘how much’. Many qualitative
studies aim to understand social situations from the point(s) of
view of those involved, whether they are the people receiving
health services or the professionals delivering them. Green and
Thorogood [8] also emphasise that qualitative research uses
language data (written or oral) rather than numerical data. A
genuinely qualitative study will employ qualitative methods of
data collection and analysis (such as in-depth interviews rather
than questionnaires), and will also present qualitative data (such
as verbal data rather than numerical data). Thus for example, a
study which collected qualitative data using semi-structured
interview methods yet presented the data only in the form of
tabulated counts of responses does not fall within the definition of
qualitative research for the purposes of this article (although
simple quantification can make an important contribution to
qualitative research) [9].
‘Qualitative methods’ is a generalised term which includes
methods located within different theoretical approaches and
which represent different epistemological and ontological
assumptions. Broadly speaking, these include interpretative
approaches, which are concerned with the ways in which human
beings interpret the world around them and the meanings they
attribute to the social world. Social constructionism, another
approach, is concerned with how phenomena are constructed;
thus for example, how certain patterns of communication come to
be established in certain institutional settings. Thirdly, critical
approaches challenge the view that research can be value free;
examples of critical research include feminist approaches and
participatory research [8]. Some specific qualitative methodologies
make explicit reference to philosophical or sociological frame-
works, such as phenomenology which draws on the work of
Husserl and Heidegger, and conversation analysis which draws on
the work of Garfinkel (see Porter [10] for an accessible overview of
these frameworks).
In the same way as the term ‘quantitative methods’ embraces a
wide range of statistical and other specialised methods, so too the
term ‘qualitative methods’ embraces a variety of particular
approaches and techniques. These include semi-structured and
depth interviews; focus groups or group interviews; observational
methods; video and audio recording; participative or action
research; and documentary analysis including analysis of visual
materials (these methods are all illustrated by Green and
Thorogood [8]). Quite often a qualitative study will include several
forms of data collection within a single study. Similarly, there is a
range of methods of qualitative data analysis including thematic
analysis; framework analysis; phenomenology; grounded theory;
conversation analysis; and narrative analysis [11]. These methods
of analysis often correspond to the different underlying theoretical
frameworks already mentioned.
As previous writers have explained, qualitative research is
appropriate when the subject matter to be investigated is ill
defined or not well understood; complex; sensitive; concerned
with processes; requires an understanding of detail; or requires
new ideas or creativity [11]. It is not appropriate for establishing
the frequency of particular communication behaviours; when the
question requires a numerical answer; when statistical associa-
tions between variables are sought; or if the researcher wishes to
test a precisely formulated hypothesis. For example, a recent
quantitative study investigated the hypothesis that a cognitive
behavioural self-help programme and a computerised structured
writing intervention would improve depressed mood in people
with HIV [12]. The results were presented quantitatively in terms
of changes in depression scores. A qualitative study of the same
issue would not have focused on depression scores but might have
385
asked ‘How did participants engage with the programme and the
intervention?’, or ‘How did the programme and intervention affect
participants’ moods or other aspects of their lives?’.
Although qualitative methods are derived from particular
theoretical frameworks, it is apparent that authors’ claims to be
using such frameworks are not always borne out in practice.
References to a particular approach, such as grounded theory, do
not always correspond to accepted definitions of that approach. It
may be more helpful to consider the general orientations of much
qualitative research, which are shared across different traditions.
Green and Britten [13] outlined five orientations of qualitative
research which are shared across theoretical approaches. These are
naturalism; interpretation; process; interaction; relativism. The
commitment to naturalism is about understanding health com-
munication in its everyday context rather than in experimental
settings. Interpretation is about investigating the meanings that
different participants in communication bring to and take away
from a particular conversation or consultation. Qualitative
research is concerned with social processes, for example, the
unfolding process of a consultation or patient journey. It is also
concerned with interaction and the ways in which one person’s
behaviour can shape, as well as be shaped by, the behaviour of
others. Finally qualitative research often takes a relativist stance,
for example by giving the same consideration to the perspectives of
patients as to those of professionals, rather than assuming that
professionals are always correct.
These orientations illustrate the differences between qualita-
tive and quantitative research. The critic might ask: what
distinctive results or outputs does qualitative research achieve;
how may qualitative and quantitative methods be combined; and
what (if any) is the cumulative contribution of small scale
qualitative studies? In addressing these questions, I aim to add
to the debate about the value of qualitative methods.
3.2. Outputs of qualitative research
Much of the discussion about qualitative research focuses on
issues to do with methods, theoretical positions, or quality
appraisal. Comparatively little time is spent on discussing outputs,
despite the fact that it is the outputs which determine the value of
qualitative research to the research community. Given the
different kinds of questions which are addressed by qualitative
research, it is reasonable to ask what its outputs might look like, if
they are not quantitative solutions to precisely formulated
hypotheses. The outputs of qualitative research may be informed
by one or more of the orientations just described, but there is no
one-to-one link between orientations and outputs. Green and
Thorogood [8] list a range of potential outputs from qualitative
research, which can all be illustrated with examples from research
about communication in health care settings. These outputs are the
development of conceptual definitions; development of typologies
and classifications; exploring associations between attitudes,
behaviours and experiences; developing explanations of phenom-
ena; and generating new ideas and theories.
3.2.1. Development of conceptual definitions
Treatment decision making is a major theme in communication
research, and many recent papers have been published about
shared decision making [14]. Few of these studies have explored
what the term ‘shared decision making’ might mean to research
participants. Entwistle et al. [15] carried out a qualitative study
exploring the meaning of ‘decisions about treatment’ by women
having a hysterectomy. In the communication literature, role
descriptions have been used to classify patients’ decisions as
active, collaborative or passive (for example, Degner and Sloan
[16]). In this study, women were interviewed and asked to describe
386 N. Britten / Patient Education and Counseling 82 (2011) 384–388
how the decision to have a hysterectomy was made. They were
then asked to complete two validated instruments of decision
control which included descriptions of patients’ roles in decisions
about their health. These were the Control Preferences Scale [16]
and the Patient Preferences for Control measure [17]. Some women
found it difficult to identify a role description that matched their
experience. Some women completed the instruments in idiosyn-
cratic ways: for example, some had agreed with their doctors’
recommendations to have a hysterectomy yet chose the ‘active
role’ on the instruments. This study showed that the role labels
that women would be assigned on the basis of their questionnaire
responses did not always fit well with their qualitative interview
narratives. The authors point to problems with the validity of the
instruments used, but their work also suggests that researchers
should re-examine the concept of a ‘decision’, for example to allow
for the fact that some decisions are taken over a period of time, and
in discussion with several individuals. The questions raised in this
paper about what the term ‘decision’ means to patients are
relevant to many other settings. We cannot be certain that
researchers’ definitions of the term ‘decision’ are congruent with
the definitions of patients. In other words, this study shows how
the conceptual definition of ‘decisions’ needs to be developed.
3.2.2. Development of typologies and classifications
The question of adherence to medication, and how it is
influenced by patient-provider communication, remains a central
theme for communication researchers. Adams et al. [18] explored
the use of medication by patients in one general practice who had
all been prescribed reliever or preventer medication for asthma in
the previous 12 months. Patients were purposefully sampled on
the basis of the ratio of reliever and preventer medication they had
requested on a repeat prescription basis, and on the basis of age
and sex. Respondents were interviewed at home and asked about
their attitudes to asthma, medication, coping strategies, normal-
isation and how these issues affected their everyday lives. The
findings of the study included a new typology of attitudes to
medication. Two main groups were identified: deniers and
accepters. The deniers refused to accept the identity of ‘asthmatic’
and were normalising their lives to the best of their abilities. They
all wished to avoid membership of what they perceived as a
stigmatised group, and had reconstructed their asthma in ways
that allowed them to deny the label or social identity of
‘‘asthmatic’’ [18, p. 194]. In contrast, the accepters had completely
accepted their condition both into their lives and their self-images.
The two groups used their asthma medication in very different
ways. A third group, the pragmatists, was identified. These people
were less accepting of the diagnosis of asthma but did not reject it
entirely; their medication use reflected this variable acceptance.
The authors’ linking of these findings to the sociological literature
on identity suggests that their findings might be applicable beyond
the context of asthma medication. The new typology developed in
this paper might therefore be of wider significance to other
researchers and those providing health care. Thus this paper
provides an example of a new typology which might be of more
general significance, in other areas of health care.
3.2.3. Exploring associations between attitudes, behaviours and
experiences
Communication researchers have an interest in professionals’
perceptions of their clients and how this can affect the care they
provide. Thus, for example, general practitioners often have
difficulty treating patients with severe mental illness (SMI) and
may prefer these patients to be seen by specialists. Lester et al. [19]
conducted focus groups with health professionals and patients with
SMI to explore their views on appropriate care, and identified a gap
in the perceptions of the two groups. Most professionals thought
that SMI was too specialised to be treated in primary care, while
most patients viewed primary care as the cornerstone of their
treatment. They valued continuity of care and preferred to see their
own GP. Further, professionals viewed SMI as a lifelong condition,
while patients emphasised the importance of optimism and the
hope of recovery. Thus this paper identifies differences in attitudes
towards SMI and its care which may help explain the behaviour of
GPs and the difficulties experienced by both professionals and
patients. The findings identify several issues which would need to be
addressed by any intervention aimed at changing either professional
or patient behaviour.
3.2.4. Developing explanations of phenomena
In addition to exploring questions about adherence, communi-
cation researchers have also explored questions about inappropri-
ate prescribing in general practice. The source of the problem is
often seen as patients’ inappropriate expectations [20]. Britten
et al. [21] explored the communication between patients and
general practitioners by audio taping GP consultations, interview-
ing patients before and after consultations, and by interviewing
GPs seeing these patients. The authors identified 14 different
categories of misunderstanding about prescription medicines; all
these misunderstandings were associated with lack of patient
participation, in terms of voicing expectations or preferences, or
voicing of responses to doctors’ actions. Misunderstandings were
often based on inaccurate guesses and assumptions; when
specifically asked, doctors seemed unaware of the relevance of
patients’ ideas about medicines. For example, one patient with
fibromyalgia planned to quit all his painkillers before seeing the
hospital specialist to avoid masking his symptoms, but his GP said
that this patient loved taking medicines. This paper thus identified
another explanation for inappropriate prescribing, which was not
focused on patients’ expectations. Instead, the authors concluded
that one factor leading to inappropriate prescribing is doctors’ lack
of awareness of patients’ perspectives about their medicines.
3.2.5. Generating new ideas and theories
One of the ‘how’ questions addressed by qualitative research is the
issue of how practitioners actually go about their daily work. A
detailed study of videotaped paediatric consultations in the US
identified the practice of ‘online commentary’ [22]. This describes the
ways in which physicians describe or evaluate (or comment) on the
signs they observe while examining a patient; for example by saying ‘I
don’t see any redness there’ while examining a child’s ear. This study
used conversation analysis to examine the ways in which practi-
tioners shaped patients’ expectations for antibiotics in situations
where doctors were unable to validate presenting symptoms as signs
of any treatable illness. Online commentary was identified as a
practice whereby doctors provide information as they are conducting
a physical examination, by describing or evaluating the patients’
physical signs. The challenge for the doctor is to reassure the patient
that it was reasonable for them to consult the doctor without
prescribing inappropriate medication. The authors hypothesised that
by using online commentary, doctors can effectively build a case for a
‘no problem’ evaluation, or one against medical intervention, while
reassuring patients of the correctness of their decision to seek help. In
other words, this study identified a new theory about how physicians
use specific communication strategies to avoid prescribing unneces-
sary antibiotics. These and other conversation analysis studies
provide detailed descriptions of actual practices, which can be
developed into testable interventions [23].
3.3. Combining qualitative and quantitative research
The increased acceptability of qualitative research has been
followed by an increase in ‘mixed methods’ research. This term
 N. Britten / Patient Education and Counseling 82 (2011) 384–388
refers to studies which use a range of methods drawn from both
quantitative and qualitative traditions. Although methods may be
combined in many ways, there are three main ways in which this
might be done. Qualitative studies may be carried out as a
preliminary to quantitative research; qualitative and quantitative
studies may be carried out in parallel as in many mixed methods
studies; or qualitative research may be used to explain or explore
the findings of a quantitative study.
Heritage’s work provides an example of conducting qualitative
research first to identify and characterise a practice which is then
tested in a randomised controlled trial [23]. Qualitative analysis of
medical consultations had identified the difference in meaning
between a doctor asking ‘have you any questions?’ at the end of a
consultation rather than ‘do you have some questions?’ Heritage
and his colleagues then conducted a trial to test the hypothesis that
the latter question would reduce the number of unmet concerns in
primary care consultations.
Investigators running randomised controlled trials are increas-
ingly likely to conduct parallel process evaluations which aim to
investigate how a new treatment or intervention is received by
patients or whether the intervention is delivered as intended
[2,24]. The work of Donovan et al. [25] aimed to demonstrate how
the design and conduct of randomised trials could be improved by
embedding them in qualitative research. Qualitative research was
used to investigate the process of recruitment to two RCTs of
treatments for prostrate cancer. Interviews with patients explored
their interpretation of study information given to them in
recruitment sessions, and these sessions were also audio recorded.
Several changes to the recruitment procedures were made as a
result: the order in which treatments were presented was altered;
misunderstood terms such as ‘trial’ were avoided; the non-radical
arm was described as ‘active monitoring’ rather than ‘watchful
waiting’ which some participants had understood to mean
watching while they died; and randomisation and equipoise were
presented more convincingly. Following these changes, the
recruitment rate rose from 40% to 70%, all the treatments became
acceptable, and the three armed trial became the preferred design.
The authors went on to investigate whether these methods could
be transferred to other trials, and made recommendations about
how this could be facilitated [26].
Rogers et al. [27] carried out a qualitative study to explore the
reasons for the lack of change in patient satisfaction arising from an
RCT of various methods designed to enhance patients’ opportu-
nities to participate in the management of chronic inflammatory
bowel disorder. They identified several potential explanations for
the results of the RCT, such as the fact that participating doctors
interpreted ‘self-management’ as compliance with medical
instructions, and the fact that doctors did not deal adequately
with patients’ concerns. The qualitative study thus provided
several explanations for the quantitative trial results, which could
have been used to change the interventions being tested.
3.4. Synthesis of qualitative research
Methods for synthesising qualitative research are less well
developed than those available for synthesising quantitative
research, such as statistical meta-analysis. However the last
decade has seen the development and establishment of several
methods, and as a result, an increasing number of completed
syntheses [28]. These methods include meta-ethnography, the-
matic synthesis, textual narrative synthesis, meta-study, meta-
narrative, critical interpretive synthesis and others (see Barnett-
Page and Thomas [28] for further details). The outputs of these
syntheses have been varied, but several have produced new
typologies, concepts or models. Thus for example, Smithson et al.
[29] developed a model of the patient journey for those people
387
using complementary and alternative medicine after a diagnosis
of cancer. They identified the experience of ‘polarisation’,
referring to the discomfort patients experienced when their
biomedical physicians were dismissive of complementary thera-
pies, in contrast to the acceptance of these therapies in integrative
settings. Malpass et al. [30] identified the concepts of the
‘medication career’ and the ‘moral career’ of people taking anti-
depressant treatments. Their model included four decisive moral
junctures which were moments of conflict when patients
wrestled with competing perceptions of social norms and
competing meanings of medications. These juncture points were
seeking help in the first place; accepting treatment; continuing
treatment; and deciding to stop. Such juncture points could
provide useful guidance for physicians treating people for
depression, by helping them to understand the different conflicts
patients may be experiencing at different points in their
treatment.
One of the differences between typologies or concepts
produced by the single studies discussed in Section 3.2, and those
produced by syntheses, is of course the larger number of studies
and therefore participants included in syntheses. The move to
qualitative synthesis might convince those critics who pay less
attention to qualitative research because of its comparatively small
sample sizes.
Those conducting these syntheses have noted that authors of
the primary studies have tended not to cite one another’s work
[31]. One of the contributions of a synthesis is thus to bring a field
together, by considering the work of different authors together
when the primary authors may not have done so, and providing a
focus for the building up of knowledge in a given field. The field of
qualitative synthesis is still developing, and many questions
remain to be explored. Given the labour intensive nature of
qualitative synthesis, one issue is how many papers can reasonably
be synthesised by a single team? It has been suggested that if there
are too many papers to synthesise, a purposeful sample of papers
could be drawn up [32].
The process of conducting a synthesis can clarify the
contribution of a qualitative study. Many qualitative studies
are descriptive accounts of ‘themes’ identified in the data. While
such studies may be useful at the early stages of investigating a
particular setting or issue (for example Britten [33]), by
providing the reader with a detailed description which brings
the setting or issue to life, too many of these studies add little to
the overall stock of knowledge particularly if they repeat what is
already known. When conducting syntheses, it becomes appar-
ent that studies which are purely descriptive and make no
attempt to develop theory, have less to offer than those studies
which make a theoretical innovation. Thus, of two papers
investigating the ways in which people with asthma use their
medication, Buston and Wood [34] provided a description of
themes associated with non-compliance, while Adams et al. [18]
developed an explanation for their findings. Adams et al.
concluded that for people who denied that they had asthma,
medication was viewed as an obstacle to normalisation, while for
those who accepted their asthma, medication was seen as an
invaluable aid to normalisation. This conclusion forms a middle
range theory which could be tested and developed in further
studies. Thus the latter paper makes a greater contribution to the
development of theory in this field. Malpass et al. [30] used the
concept of key papers, to refer to those which were conceptually
rich and contributed most to their synthesis. They found that
removing papers not rated as key papers had no apparent impact
on the synthesis. If this result is replicated elsewhere, it suggests
that in situations where there are large numbers of papers
available for synthesis, it would be appropriate to base the
synthesis on a purposeful sample of key papers.
388 N. Britten / Patient Education and Counseling 82 (2011) 384–388
4. Discussion and conclusions
4.1. Discussion
This article has contributed to the debate about the value of
qualitative research by illustrating its distinctive outputs; the
various ways it can be combined with quantitative research; and
the comparatively recent development of methods of qualitative
synthesis. Although qualitative research is often characterised as
providing descriptions of patients’ experiences [34], the challenge
for qualitative researchers is to become more ambitious than this.
By moving beyond description and emphasising the development
of new concepts and theories, qualitative researchers can help to
unpack the processes surrounding healthcare communication and
explain ‘how, why and what’ is going on. The synthesis of
qualitative research offers the opportunity of building up a
cumulative evidence base comparable to the growing evidence
base of quantitative research, which is based on much larger and
more diverse populations than those of single studies. In this way,
the early criticism of qualitative research – that it is based on small
and unrepresentative samples – is less and less relevant.
Qualitative synthesis also offers the opportunity of developing
more comprehensive theoretical and explanatory models.
4.2. Conclusions
Qualitative research has already made an important contribu-
tion to the health communication literature. In future we may
anticipate more empirically based explanatory and conceptual
models which further our understanding of the processes of
communication in real life settings.
4.3. Practice implications
The further development of methods of qualitative research
will be enhanced if qualitative researchers move beyond descrip-
tive studies and aim to provide explanations and not just
descriptions; if qualitative researchers – where appropriate – cite
each other’s work more often, and conduct more syntheses, thus
helping to build a cumulative evidence base; and continue to work
with quantitative researchers on mixed methods studies aiming to
provide fuller and more rounded pictures than is possible when
using either quantitative or qualitative methods alone.
Conflict of interest
I have no conflict of interest in relation to this article.
Role of funding source
Nicky Britten is partially supported by the National Institute of
Health Research in the UK.
Acknowledgement
I thank Melanie Neumann for her helpful input as one of the
editors of this series.
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