Getting under the skin: qualitative methods in dermatology research

Qualitative methods enable researchers to make sense of people's beliefs, emotions and behaviours by paying attention to the detail of their lives and perspectives.1 They work predominantly, although not exclusively, with words rather than numbers, using flexible but systematic methods to gain insights into issues of importance to research the participants themselves. They can tell us how people conceptualize things and why they do what they do, by probing the ‘what?’, ‘why?’ and ‘how come?’ of their beliefs and behaviour.2, 3 When used well, qualitative methods ‘reach the parts other methods cannot reach’,4 capturing new insights that would otherwise remain hidden by the use of more traditional, structured approaches. So can these methods bring something new to dermatology research? Clearly yes, if you count getting under the skin (pun intended!) of dermatology policy and practice to help address the significant physical, psychological and social demands that living with a dermatological condition can bring to patients and their families.5 If you want to know why your patients don't use their treatments as recommended, why uptake of a new service is low or why the results of a clinical trial do not translate easily to clinical practice,4 using qualitative interviews, focus groups, observational methods, or documentary or visual analysis could help you find the answers.6 The strength of qualitative approaches lies in being able to research in depth the context in which dermatology practice occurs (what's happening on the ground) and its process (how and why it is happening). This can help to improve the content, delivery or organization of services in ways that are grounded in and relevant to the specifics of dermatology. Qualitative methods can help you get a richer understanding of factors that affect your patients' quality of life, self-esteem, mood, resilience, self-management, coping and adherence to treatments. These approaches can identify patient-centred goals and unmet support needs or new training requirements for dermatology professionals, and enhance the study of patient–professional communication, treatment decision making and patient satisfaction. Qualitative research has a long history in anthropology and sociology, more recently making the leap to psychology and applied healthcare research. Nevertheless, until now, such methods have been less visible in dermatology than they ought,7 given that patient values are a core component of evidence-based medicine.8 The methods can be used independently or in combination with quantitative techniques, the key being to choose the right tool for the job, selecting your methods on the basis of their fit with the aims of the research.6 U.K. Medical Research Council guidance on the development of complex interventions to improve health recommends the integrated use of qualitative and quantitative methods in intervention design, implementation and evaluation.9, 10 This enables more focused hypotheses, grounded in the experiences of people living with or providing care for skin conditions. Consequently, high-quality, in-depth qualitative research is key to shaping dermatology-specific patient-reported outcome measures or the content, delivery, evaluation and improvement of new interventions to inform treatment decision making and patient management in dermatology practice. Like all research approaches, qualitative methods can be applied poorly11 if understanding of the underpinning principles is inadequate or skills in the techniques are lacking. There is sometimes a view that qualitative research is ‘common sense’ and thus can be done by anyone, or worse that it is ‘unscientific’ or ‘anecdotal’12 and ought not to be done at all! However, markers of quality (such as ‘purposive’ and ‘theoretical’ sampling to obtain diverse perspectives, or ‘constant comparison’ to compare and contrast emergent themes in a dataset) can be appropriately applied in the design, conduct, analysis and reporting of qualitative research to produce robust and credible findings.6, 13 This journal is at the forefront of publishing rigorous qualitative work that contributes new insights into dermatology. These findings often go beyond ‘static’ description to a dynamic explanation of the data gathered, telling us a coherent story about the clinical setting3, 11 that was unseen in previous research using more structured methods. For example, the Dermatology Life Quality Index can offer some indication of quality-of-life issues for patients, but only in-depth interviews demonstrated the extent to which cultural values related to appearance were influencing the psychological adjustment and social functioning of South Asian women with vitiligo.14 While survey data have previously identified the low doctor consulting rates among people with psoriasis, qualitative interviews uncovered the reasoning behind people's reluctance to consult.15 Participants believed that the distress associated with living with psoriasis was often trivialized by doctors in consultations, undermining their confidence to self-manage. These two studies, both reporting findings from diverse samples, also highlight the value of qualitative approaches in involving so-called ‘hard-to-reach’ groups in dermatology research. In this issue of the BJD, interviews by Selman et al. with the caregivers of patients with cutaneous T-cell lymphoma reveal the family impact of living with this condition.16 This work is an elegant example of how applying a pre-existing theoretical framework (in this case a model from family systems theory) can make sense of and give another perspective to a new and complex qualitative dataset to powerful effect.17 Qualitative interviews have for the first time also brought to light the detailed experiences of dermatology clinicians themselves,18 demonstrating that the way clinicians construct their professional role can be a barrier to supporting patient behaviour change, and that they are not currently confident or trained to deliver such support. Creative methods have long been part of qualitative documentary and visual analysis approaches, but have recently been applied to dermatology as a novel technique.19 The powerful textual and visual representations of psoriasis that were gathered highlighted the ways in which people think about psoriasis and how these significantly impact upon their emotional and social functioning. Write-and-draw methods were able to go beyond language to help people unlock and articulate their experiences through compelling images and text. Bringing hidden perspectives into view is only part of what qualitative methods can offer to dermatology. Crucially, qualitative observational methods allow detailed investigation of what happens as it happens, to reveal not only what people say they do, but also what they actually do in practice.6, 11, 12 Observational methods have been newly applied in dermatology, in a mixed methods study of cardiovascular disease (CVD) risk communication between primary care practitioners and patients with psoriasis.20 The combined analysis of biomedical risk assessment data, audio-recorded real-time consultations, and subsequent interviews with patients and their practitioners, has revealed what is happening in current CVD risk screening practices, as well as the reasons why opportunities to support patients with psoriasis to reduce their CVD risk, are being missed. We owe it to patients with skin disease and their dermatology health professionals to push methodological boundaries in the field, not only making qualitative methods an established component of dermatology research but also moving beyond the more conventionally employed interview and focus group methods to incorporate the use of creative, observational and mixed methods approaches.11, 12 This will enable development of interventions to imp-rove dermatology care that are grounded in the real-world experiences of patients, their families and their health-care professionals (see the Impact Psoriasis website for an example).21 Well-designed, well-executed, in-depth qualitative research requires skilled researchers to get beyond participants' face-value accounts and reveal processes that can help improve patient care. This journal is spearheading the mission to publish high-quality, innovative qualitative research to add to the dermatology evidence base and its practice. Dr Christine Bundy, Dr Lis Cordingley and Professor Sue Kirk of the University of Manchester previously reviewed a version of this manuscript. None declared.