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This blog was created to keep healthcare professionals, researchers, methodologists, and patients up to date with the latest primary care research. For more information about the Research Institute, visit our website; keele.ac.uk/pchs

Friday, 1 December 2017

'Are we there yet?' Saturation in qualitative research and how to use it

Written by Dr Ben Saunders | www.keele.ac.uk/pchs | @PCSciences



I think I speak for most qualitative researchers when I say saturation is taken for granted, yet there continues to be inconsistency in how it’s used and even uncertainty on how to use it. Drawing on our recent published paper, this blog tackles the ‘what, where, when, why and hows’ of using saturation in research.  

What is Saturation?


In short, saturation is used as a criterion for qualitative researchers to decipher when data collection or analysis is discontinued – in essence they reach ‘saturation point’. But this is research methodology we’re talking about, so it’s never going to be short and sweet.

From analysing existing literature, we’ve been able to identify four approaches to saturation, which may be either inductive (exploratory - finding patterns of explanations/theories) or deductive (using data to test pre-determined theories);

Theoretical saturation (inductive)

Data analysis leads to well-developed theories where no aspects remain hypothetical. The researcher(s) reaches the decision that no further data collection is needed.

Inductive thematic saturation

Similar to theoretical saturation, but it focusses on the identification and number of ‘new’ codes and themes rather than the completeness of theoretical categories.

A priori thematic saturation (deductive)

Establishing whether there is enough data to illustrate a pre-determined theoretical category.

Data saturation

Moving away from data analysis, this is based on how much data (i.e. the number of interviews) are needed until you’re no longer finding anything new.

Where and why should we use saturation?


The role of the theory is hugely influential to the relevance and meaning of saturation. In both deductive and inductive approaches, we are able to make sense of the role of saturation because of the underlying approach to the analysis being thematic. It will usually occur in interview or focus group studies that involve a number of informants.

It’s less straightforward in studies based on biographical or narrative approaches to analysis because they focus exclusively or predominantly on the accounts of an individual (e.g. interpretative phenomenological analysis). It might appear that saturation indicates completeness of a biographical account, but this is questionable. Can saturation usefully describe a participant’s story as ‘complete’ given the distance that it moves us away from the use of saturation in thematic approaches? Surely this would stretch the coherence and utility of saturation too widely? 

When and how?


Perspective will have a big implication on when saturation should be sought. Saturation can be identified early on if you take the ‘data saturation’ or/and ‘inductive thematic saturation’ approach. Data saturation will rely on the researcher’s perspective on what they’ve heard during interviews to decide whether further data collection is needed. Inductive thematic saturation looks for the (non)emergence of codes or themes.

In contrast, theoretical saturation is reached much later, often when grounded theory categories has been developed, so analysis is much more advanced.

Straus and Corbin quite rightly highlighted the issues with identifying the point of saturation and whether it’s just a cumulative judgement. Although it’s commonly seen as a discrete event, there will always be the potential for ‘new’ codes or theories to emerge. Analysis will therefore not suddenly become ‘rich’ or ‘insightful’ after the addition of one interview, rather it becomes ‘richer’ or ‘more insightful- raising the question ‘how much saturation is enough’ rather than ‘has saturation occurred’.

Attempting to identify the right point of saturation perhaps reflects the uncertainty of how to use it. Determining whether further data collection or analysis is needed, based on the data already gathered, essentially refers to the unobserved based on the observed – an uncertain predictive claim which can only be tested if the decision to halt data collection is overturned.

So, if saturation is unpredictable, what’s our advice? Here’s our top 4 points to consider when using saturation in your research….

 

Define its purpose

The relevance of your saturation and its meaning will depend on the role of the theory and the analytical approaches you’ve adopted etc. Therefore, it may serve different purposes for different types of research – purposes that need to be clearly articulated by the researcher.

Don’t saturate your saturation

There needs to be a limit on your range of purposes for saturation, or else you run the risk of stretching or diluting its meaning to the point where it becomes too widely encompassing.


Event or ongoing process?

When to use saturation, and how you reach saturation will differ depending on the type of study. Assumptions about whether it represents a distinct event or ongoing process will also differ.

Recognise its inconsistencies

If anything, this paper confirmed the need for a more transparent reporting of saturation, as well as a thorough re-evaluation of how it’s considered and used – including the recognition of potential inconsistencies and contradictions in its use. Considering the four different types of saturation outlined earlier will help serve as a guide for this.


The blog was adapted from the following paper:
Saunders, B., Sim, J., Kingstone, T., Baker, S., Waterfield, J., Bartlam, B., Burroughs, H. and Jinks, C. (2017). Saturation in qualitative research: exploring its conceptualization and operationalization. Quality and Quantity. https://doi.org/10.1007/s11135-017-0574-8.

About the Author
Dr Ben Saunders is a Qualitative Research Associate at the Research Institute on the Stratified Primary Care Programme, and is an active member of the Social Science team. He is involved in the development and testing of a new stratified care intervention for treating common musculoskeletal conditions in primary care, and is also working on a number of research projects. Before joining the Research Institute, Ben completed his PhD at Cardiff University where he researched young adults’ experiences of living with long-term conditions, focusing on inflammatory bowel disease (IBD) and Type 1 diabetes. Ben currently supervises PhD students in the areas of stratified care, dementia caregiving, and young people’s experiences of stoma care.


Monday, 30 October 2017

Symptoms of trauma: beyond PTSD

Written by Professor Athula Sumathipala | www.keele.ac.uk/pchs | @PCSciences

Professor of Psychiatry, Athula Sumathipala attended the 16th Congress of the International Federation of Psychiatric Epidemiology in Melbourne, Australia from 17th-20th October. This year’s event focussed on the priorities in global health - taking psychiatric epidemiology to scale. In this blog,  Athula summarises his keynote address which focused on the epidemiology of conflict, migration and mental health in Sri Lanka, where he stresses that Common Mental Disorders (CMD) and unexplained physical symptoms are often ignored because of an undue emphasis on post-traumatic stress disorder (PTSD).



PTSD has always been considered to be the main consequence of patients who have experienced trauma. Recent research which has been conducted in Sri Lanka shows us though, that non-PTSD psychiatric diagnosis has a higher prevalence in patients exposed to trauma than PTSD itself.

Citizens in Sri Lanka have experienced considerable trauma over the decades. The country was victim to two uprisings since the 1970s by its predominant Sinhala ethnic group, as well as ongoing armed conflict by the Tamil rebels for over 30 years. A devastating tsunami also displaced over 500,000 citizens, killing 35,000 victims and significant outward migration abroad has occurred due to economic crisis.   

A National Mental Health Survey which was commissioned by the Ministry of Health in Sri Lanka assessed a population of 6,000, revealing that 1 in 10 Sri Lankans have some form of common mental health disorder because of experienced trauma. Overall, depression was most prevalent at 9.1%, with Somatoform Disorder (unexplained physical symptoms) at 2.9%. PTSD was only reported at 1.9%.

Reports of common mental health disorders were considerably more prevalent (19%) in a group of individuals who were forcibly displaced by the Tamil Tigers from the Northern Province of Sri Lanka over the last 20 years. Depression was reported at 12% and Somatoform disorders at 14%, PTSD was under 3%.

An alternative study conducted in the Colombo district which has a sample size of 6,000 also showed that although traumatic events were reported at 36.3%, 2% of those individuals experienced PTSD and 19% experienced non-PTSD mental illness over their lifetime.  

On a whole, we know that 1 in 10 Sri Lankan adults experience some form of mental disorder, which doubles in specific groups, such as trauma affected groups. Somatic distress appears to be considerably high, but receive inadequate attention from healthcare professionals.  

These findings have been invaluable in demonstrating that the domination of PTSD as the main psychiatric consequence of trauma is misguided, particularly in Sri Lanka. Mental health clearly has a much wider focus and needs to include depression, anxiety and somatic symptoms. The research has also raised awareness that child and adolescent mental health is a crucial issue which also needs addressing. child and adolescent mental health is a crucial issue which also need desperately addressing.

About the author:


Professor Athula Sumathipala 
Athula qualified as in Sri Lanka and trained as a family physician before re-training as a psychiatrist a the Maudesley and Bethlem Royal Hospitals. Athula later followed an academic career, and completed a PhD at the University of London. Athula has a particular interest in inter-connected disciplines such as the epidemiology of chronic disease and morbidity, the evaluation of complex interventions, using twin methods in study of illness aetiology and ethics related to research. 

Thursday, 26 October 2017

Utilising patient power to evolve research implementation

Written by Robyn Till | www.keele.ac.uk/pchs | @PCSciences | @KeelePPIE



Friday 13th October was anything but unlucky for the Research Institute’s (RI) Patient and Public Involvement and Engagement (PPIE) Team, who were joined by over 80 patients, stakeholders and researchers for their annual Research User Group (RUG) event. This year’s event entitled ‘accelerating the impact of research using patient and public involvement’ was a huge success, leaving all those involved feeling rather inspired to make a difference to the way the RI implements research into practice.

Dr John Bedson showcasing the Keele Pain Recorder

Keele Hall’s ballroom was buzzing with enthusiasm as participants made introductions or caught up over their morning coffee and cake. Delegates could be found talking to representatives from Arthritis Research UK (ARUK) and the National Institute for Health Research (NIHR), or chatting to our very own Dr John Bedson, who was showcasing the Keele Pain Recorder (a mobile app designed by Keele’s Research User Group, aimed at improving pain management).
 

RI Director, Professor Elaine Hay, who was stepping in for Professor Krysia Dziedzic (Director of the Impact Accelerator Unit and PPIE) set the scene for the day. She welcomed the development of the Impact Accelerator Unit over the past 12 months and recognised the positive changes this has made to PPIE - which is now an integral part of Implementation as well as research. Promising it wasn’t something straight out of a Star Trek movie, Elaine summarised that the unit was about proactively managing the process of implementing research findings into health care by using patient power. She congratulated all of those involved in PPIE over the years for all their hard-work and dedication, which put PPIE on the research map.
Professor Sophie Staniszewska, Warwick University

Our keynote speaker took the stage next - Sophie Staniszewska, Professor of Public Involvement and Engagement at Warwick University. Sophie highlighted that studies often fall victim to ‘research waste’, where findings are either not implemented into routine healthcare or take up to 17 years to be implemented.  But, she feels that the promising concepts of co-production and knowledge mobilisation can go a long way in improving the research to implementation gap.


So what does she mean? Quite simply, it’s ensuring that clinicians, economists, academics and patients are all involved in the co-production of each element of the research cycle. This includes study design, research output design, development of guidelines and implementation activities. This can be done through a ‘knowledge mobiliser’ or ‘knowledge broker’ - a champion that bridges the gap between all of these structures.
Research jargon out the way, it was time to hear from the stars of the show, our patients.
Patricia Callaghan, LINK Group Member
Magdalena Skrybant, a member of our LINK (Lay Involvement in Knowledge Mobilisation) group, highlighted that as a patient involved in the research process, it can be really satisfying to see that research published in a journal, but fast forward ten years and it’s still not been translated in practice. Aware that processes are slow, she reiterated the importance of patients in improving the design and delivery of research by providing their patient insights and experiences, whether it’s helping to create publications that signpost patients to the right places, or helping disseminate a mobile app that a researcher has developed. Patricia Callaghan, also provided her insights as a LINK group member as she pulled on a few heart strings, taking the audience through her journey to becoming a member.
Breaking up the day with a bit of light comic relief, we welcomed back our two favourite Grannies, Ethel and Agnes. Ethel and Agnes (played by two budding actresses, and members of the PPIE team) helped demonstrate how daunting the process can be joining the research - and now implementation - world as a non-academic. This year they were joined by a member of RUG on stage, who played the part of Ethel’s husband.
Ethel (Adele Higginbottom) struggles to understand the
research terminology
Following a morning which focussed on how patient power needs to be better utilised to improve implementation, the afternoon looked at how Keele has successfully done this, through the JIGSAW-E (osteoarthritis) and STarT Back (back pain) implementation projects. The role of Patient Champions in the European wide JIGSAW-E project were showcased by Implementation Project Manager Nicki Evans and LINK member John Murphy, whilst Knowledge Broker Laura Campbell and Consultant Physiotherapist / NIHR Knowledge Mobilisation Fellow Kay Stevenson presented the global progress of STarT Back through a novel ‘Mastermind’ format.

The LINK group, which was mentioned a number of times throughout the day, was created over a year ago, and is made up of people with a passion and enthusiasm for improving healthcare using the best possible research evidence. This group is tasked with providing guidance to the Impact Accelerator Unit project team by drawing on their knowledge, contacts and experience of the NHS and healthcare practice.

Sue Ashby, PPIE Implementation Fellow, has been researching the work of the LINK group and the impact of the patient voice over the last 12 months. With the help of RUG members Katie Tempest, Ruth Haines and John Haines, Sue explained that although there is a lot of literature out there which tells us how we can meaningfully involve patients in research, it isn’t telling us how its done in implementation. In reaction to this, Sue researched how to use PPIE in implementation by reviewing case studies and literature, interviewing patients, researchers and clinicians at Keele, and observing LINK meetings. 
It wouldn’t be an RI event without some audience participation, and Helen Duffy, NHS Partnerships and Engagement Manager and co-director of the Impact Accelerator Unit was on hand to facilitate. Delegates were asked to think about how they, as an individual, could improve research implementation.
The consensus around the room was that using networks, exploiting communication methods such as the media, improving clinician’s mind-sets, educating healthcare professionals and ensuring consistency across healthcare practices would make a real difference.  

All in all, the event was a great success and it was fantastic to see so much enthusiasm for PPIE from not just the patients, but from the academics and stakeholders as well. The work that has been done by the team has put PPIE on the research agenda  and ensured that it has become best practice. Now it’s about opening up a dialogue and changing perspectives of all those involved in research by emphasising the importance of patient power.

Visit the our Patient and Public Involvement and Engagement website for more information about the Research User Group.