Answering “How” and “Why” Questions: The Value of Qualitative Research in Mental Health

Research is vital for the ongoing progress of society and organizations, including mental health care. It brings new insights that inform improvements in treatment and care and thus the continuing growth and development. Within the medical context, research has traditionally been quantitative, involving testing and comparing, or counting and measuring "quantities," which includes the majority of psychiatric research in India. A review of the literature examined the prevalence of different types of research published in the Indian Journal of Psychiatry or presented at the Annual Conference of the Indian Psychiatry Society between 2010 and 2019. It was found that only 12 out of 356 articles and 28 out of 2297 abstracts had qualitative elements, with <1% or 25 out of the total of 2653 articles being purely qualitative (as opposed to using mixed methods).[1] The researchers conjecture that in part this is due to a lack of trust in qualitative research, as it is perceived as being less scientific, which leads to a lack of training in qualitative methods and so a lack of knowledge and skill to undertake research in this way. However, it is inarguable that not all things can be understood by counting, comparing, or measuring, and at times, different ways to gain insights need to be found, particularly in regard to why people think and behave as they do, including the subsequent impact on lives and services.[1] Bayetti, Jadav, and Deshpande[2] particularly address the need for more qualitative research in relation to how medical students and psychiatry trainees learn psychiatric skills and knowledge, how psychiatrists construct their professional identity, and how both issues interrelate with the Global Mental Health Movement and its applicability or nonapplicability in the Indian medical context. Despite both these articles calling for more qualitative research, they also concede there is a lack of knowledge and training in how to undertake it. Over recent years, qualitative methodologies have been increasingly used in medical research in India,[3] including in mental health research,[4-6] and have proven able to offer insights to improve patient care and outcomes that purely quantitative methodologies are unable to address. For such valuable insights to grow and impact lives, the psychiatry community needs to learn how to produce robust, rigorous qualitative research and be validated by the wider psychiatric community to do so. In this editorial, we put forth the essential elements of qualitative research and address the main criticisms of the application. We conclude with a description of how one qualitative research methodology, namely constructivist grounded theory (GT), was used in a medical college in Mumbai, to understand how and why medical students often disengage from psychiatry education, a question unable to be answered by quantitative methodologies alone. THE BUILDING BLOCKS OF RESEARCH Research can broadly be defined as to find out about something that is unknown – to search for it, in order that new knowledge or insight and understanding might be gained. It can take more than one look – as into re-search, repeating the seeking process. This re-searching process is usually motivated by a gap in knowledge or something that we do not know that we want to understand to improve the efficiency or impact of an intervention or services or the user experience. The most important factor when undertaking research is ensuring, there is alignment between this knowledge gap, as in what needs to be understood, and the way it is found out, as in the right research methodology or tool for the job. The starting point should always be the gap in knowledge, which will generate the research questions, which will indicate the best methodology, not the other way round. Congruence between the knowledge gap, questions, and methodology is important if fit-for-purpose research is to occur and create the necessary insights and improvements. Once the methodology is clear, the most appropriate methods of data collection and analysis become obvious. In addition to alignment between the gap, questions, methodology, and methods, there also needs to be awareness of how the researcher is situated within the research process, which is more significant in qualitative research. In addition to what the researcher believes about reality and how that reality can become known, as in their ontological and epistemological stance, the positionality of the researcher in relation to both the research subjects and the data generated is also highly significant. Positionality is informed by prior knowledge of the research situation and status with participants and incorporates the researcher's values and assumptions – their axiology. In qualitative research, addressing researcher positionality and axiology is vital, as they influence every part of the research process. This is not necessarily negative but needs to be addressed to ensure robust and valid research. Figure 1 shows how the different elements of any methodology align and influence each other, with axiology and positionality underpinning the whole process.Figure 1: The relationship between the different elements of the research process[ 7 ]PARADIGMS – WHERE QUALITATIVE RESEARCH FITS Most common research methodologies group together under three main research paradigms or ways of perceiving/approaching the world, i.e., Positivist; Interpretivist; and Critical Theory. The differences between paradigms relate to beliefs about the nature of reality (the ontology), along with how that reality can "come to be known" (the epistemology). The ways the researcher can "come to know" produce the range of research methodologies that are aligned with the ontological and epistemological positions, and the three together – ontology, epistemology, and methodology-form the research paradigm. There are many research paradigms, with many subdivisions. Table 1 outlines the three main paradigms which are at the root of most research methodologies.Table 1: Outline of common research paradigms[ 7 ]Qualitative research is generally situated in the interpretivist paradigm, although it can form a part of a critical theory approach if there is a specific focus on power dynamics. Qualitative research is exploratory, seeking to understand experiences, perceptions, attitudes, and behaviors around a particular phenomenon within its sociocultural context.[3,8] It is most commonly inductive, meaning it does not seek to prove or disprove a hypothesis, but instead, explores questions about an individual or social phenomenon to gain insights which are built upon in an iterative process. In some methodologies, these insights can then be abductively tested. The key elements in qualitative research are shown in Table 2.Table 2: Key elements of qualitative researchQUALITATIVE METHODOLOGIES AND METHODS Qualitative methodologies There are many forms of qualitative research, and the most appropriate methodology will depend on the research purpose and so the questions, the context where the research takes place, and the philosophical position of the researcher. Table 3 outlines the common qualitative methodologies.Table 3: Common qualitative research methodologiesQualitative questions The type of questions that are asked in qualitative research seeks to understand how and why specific situations or behaviors occur. Researchers commonly look for patterns in the thinking, behaviors, or attitudes of participants, with the purpose of generating insight to improve those situations or behaviors. Example qualitative research questions could be: How do rural communities in Uttar Pradesh experience access of mental health services Why is there low concordance with antidepressant medication among young people in Mumbai How do families with an elderly relative with Alzheimer's care for them in their communities Why do 97% of medical students in New Delhi did not choose psychiatry as a postgraduate specialism. If these were the pertinent gaps in knowledge, then qualitative methods would provide the necessary means to answer. Methods in qualitative data gathering and analysis As qualitative research wants to explore and understand the experiences, attitudes, perceptions, and behaviors of individuals or groups of people, the most common methods of data collection focus on asking the people involved. The asking can be in person, often through interviews or focus groups, or in writing such as through qualitative questions on a survey, or at times through questioning the content of written documents such as case notes or policies. Observation can also provide insights, accompanied by informal discussion to understand why the observed behaviors occur. Data analysis in qualitative research commonly involves transcription of interactions or observations, then labeling or coding significant words that occur across the data. The codes are then grouped by themes or concepts and through a reflective or comparative process, interpretations are made, and, in some methodologies, theories are generated. Different methodologies name this process in different words but follow a similar pattern. QUALITATIVE RESEARCH – COMMON CRITICISMS Subjectivity of the researcher The likelihood of the researcher bringing subjective beliefs and assumptions to the research process is inarguable. However, in high-quality, robust qualitative research, mitigations are put in place to counter bias. Reflexivity is the key tool, involving a systematic process of questioning researcher motives and their influence. One format to aid the reflective process is the presuppositional interview,[9,10] which provides a means to bring bias to the forefront of consciousness so as to create a framework of awareness against which to hold research decisions to account. The use of critical supervision can also provide accountability and challenge across the process. Lack of robust analytical processes Each qualitative methodology has a specific method or structure of data analysis, which when followed precisely and reflexively, will lead to clear insights in the findings that will be representative of the data being explored. To ensure rigor and the credibility and validity of qualitative research, it is important to follow the analytic process of the chosen methodology precisely, with transparency. Qualitative data analysis software, such as NVivo, can help demonstrate that a robust process is followed and that interpretations are traceable back to the data in an auditable manner. Some methods of analysis also use more than one researcher and compare codes, looking for commonalities in interpretation. Others use specific accuracy processes such as member checking, where once transcribed or analyzed, findings are taken back to participants to check that an accurate record has been created. It is important to note, however, that across all qualitative research, there is an understanding that reality is subjective or relative, that different people will interpret meaning differently, and that there is no need for consensus for findings to have value. If the researcher has an intent to understand different perspectives to fill a gap in knowledge and follows valid, robust research processes with rigor, valid research findings that bring valuable insights will result. Lack of generalizability Qualitative research by nature uses a much smaller data set than quantitative research. It does not set out to be generalizable across all similar circumstances but seeks to generate understanding where there is a lack. Thus, it aims at a depth of knowledge in a specific context, not universal knowledge. That said, findings generated in one situation, such as a rehabilitation facility in Kolkata, may well hold similarities in another rehabilitation facility in Chennai, as some of the circumstances may be similar. To understand the experiences of ten mothers with a child with autism 'will not mean that all mothers will have that same experience, but for those ten, insights may be gained that could be life-changing. There are also likely to be commonalities in their experience that will resonate with many mothers of children with autism, and how those ten felt and learned to provide for their child's needs, may prove extremely useful for others. This is what is known as transferable knowledge, where circumstances and experiences are acknowledged as not being the same, but nevertheless, insights gained can make a positive difference in a wider field. A CASE EXAMPLE Between 2020 and 2023, qualitative research was undertaken in a Government Medical College in Mumbai to understand how and why medical students engage in or disengage from psychiatry education,[7] with engagement in this context meaning at a cognitive, behavioral, and emotional level.[11] Purpose and question For almost 60 years, the psychiatry education literature has said that India does not have enough psychiatrists to meet the mental health needs of the population, and therefore, there is a need to train medical students, so that when qualified doctors, they may address the deficit.[12,13] However, the literature repeatedly reports that many medical students do not attend psychiatry education,[14-17] and so have not learned the necessary knowledge or skills to help. There have been many opinions in the literature as to why this lack of engagement exists, but no one has ever asked the students why or tried to understand their views, beliefs, and experiences. The purpose of this research was, therefore, to fill this gap in knowledge by asking the question: how and why medical students engage in or disengage from psychiatry education in India. Methodology As the question involved gaining an understanding of a social process (engagement or disengagement in psychiatry education) through exploring the perceptions of medical interns as to their experiences, GT was chosen as the most appropriate methodology. The constructivist form of GT was chosen as it allowed for co-construction of understanding between researcher and participants, in line with a relativist ontology and a social constructivist epistemology. The research process was inductive and iterative in the first two phases, then abductive in the final phase. Methods of data collection and analysis Data were collected using focus groups and interviews, with a questionnaire across 10 States of India being used in the latter phase to test the emerging theory with a wider pool of participants. Data analysis used transcription and coding, with each phase of data collection becoming more purposive to gain a greater depth of insight into the emerging categories (themes). The constant comparison method was used throughout to compare the iterative data with the codes and categories and a system of written memos (tentative interpretations as to meaning) was maintained to ensure insights were linked (or grounded) back into the data. Diagramming of the emerging patterns and concepts aided insight and was shared with participants in the latter stages to ensure accuracy or testing of understanding. Researcher positionality and reflexivity The main researcher was not from India but from the UK, and as such was very aware of potential Western bias in assumptions, both about the content of the research, and the appropriate way to undertake the exploration. Principles of decolonization in intercultural research were applied to the whole process, including an intent for reciprocity; a robust system of reflexivity, including a presuppositional interview and a framework of post-colonial critique for all decisions made; and an adaptation of praxis to counter Western-imposed research methods, ensuring agency remained with the interns. The methodology of constructivist GT aligns well with decolonized research, with co-construction and reflexivity remaining central tenets. RESULTS The findings generated a theory of disengagement to explain how and why medical students disengage from psychiatry education in India.[7] This held significance as the reasons given by the interns were different to what has been published in the psychiatry literature for almost 60 years, reasons based on the views of senior psychiatrists in the field, but not on robust qualitative research. Through asking the interns themselves how and why they disengaged, insights were gained beyond what was previously "known" or assumed, and on these insights, recommendations for change at a governmental level have been published, and practical means to enable nonpsychiatrists to address the mental health needs of the nation are being explored. SOME MERITS OF QUALITATIVE RESEARCH IN MENTAL HEALTH Qualitative research offers numerous advantages in the field of mental health, providing rich, in-depth insights into the complexities of human behavior, experiences, and interactions.[18,19] Qualitative research captures the lived experiences of individuals, offering a nuanced understanding of their mental health journeys. It provides context to mental health issues, revealing how they are experienced in daily life and influenced by social, cultural, and environmental factors Qualitative methods are well-suited for exploring complex and multifaceted mental health phenomena that are difficult to quantify. They allow for a holistic view of mental health, considering the interplay between various factors (biological, psychological, and social) that contribute to mental well-being Qualitative research designs are flexible and can be adapted as new insights emerge during the study. Researchers can refine their questions and approach iteratively, ensuring a deeper exploration of emerging themes It empowers participants by valuing their voices and perspectives, often giving voice to marginalized or underrepresented groups. The participatory nature of qualitative research fosters a collaborative relationship between researchers and participants, enhancing the validity and relevance of findings Qualitative research is instrumental in developing new theories and hypotheses grounded in real-world data. It is particularly useful in exploratory phases of research, where little is known about a phenomenon, and initial insights are needed to inform further study It can identify previously unconsidered variables and dimensions of mental health, leading to more comprehensive understandings and new research directions. The detailed data obtained can reveal subtleties and complexities that quantitative methods might overlook Qualitative research is sensitive to cultural differences, helping to understand how cultural contexts influence mental health experiences and perceptions. It provides insights specific to cultural or social contexts, which is crucial for developing culturally appropriate interventions Insights from qualitative research can inform more patient-centered approaches in clinical practice. It helps in designing interventions that are better tailored to the unique needs and circumstances of individuals and groups. Qualitative research plays a vital role in advancing mental health knowledge by offering deep, contextual, and nuanced insights into individuals' experiences and the complex interplay of factors affecting mental health. CONCLUSION Where there is a lack of knowledge or understanding, research is always positive. To align the question that needs to be answered with the most appropriate methodology is vital. If the questions are about understanding how and why a situation occurs, qualitative research can answer, whereas quantitative research is not. When following robust methodological rigor incorporating researcher reflexivity, qualitative research can produce insightful knowledge with wide implications for practice, and so impact the lives of many. To learn more about how to do this in the Indian psychiatry context would seem essential. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.