gms | German Medical Science

Qualitative research is increasingly used in public health and medicine [1]. To account for this development, it is desirable to educate future researchers and practitioners in these fields on how to conduct and evaluate qualitative research. Qualitative health research can be defined as an inductive research approach used for exploring health and illness, while considering the perspective of the people themselves, rather than the researchers’ perspectives [2]. By using qualitative methods, researchers elicit emotions and perspectives, beliefs and values, and actions and behaviors for the purpose of understanding the participants’ point of views responses to health and illness, the meanings they construct about the experience, and their subsequent actions [2].

Qualitative methods in public health are particularly applicable to assess the personal understanding of health risks, stress factors and illnesses, complex cognitive appraisals and reflections, life course and biographical processes, the social and biographical context of basic factors and the complex relationships between these factors [3]. In the field of medicine, qualitative research is increasingly used to describe, understand and improve certain aspects of medical practice [4], [5], [6], [7], [8], [9], [10]. The application of qualitative methods to medicine allows a researcher for instance to gain a deeper knowledge about the doctor-patient-interaction, the subjective or social meaning(s) of illness, disability or a medical treatment measure or the process of medical decision-making [4], [11]. The methodology of qualitative inquiry is reflected upon in a broad range of medical disciplines including general practice [5], [6], psychiatry [7], [8], oncology, palliative medicine [9], [10], dermatology [12], radiology [13] or critical care [14], [15] With the rise of qualitative research in medicine and public health, the combined use of both methods – qualitative and quantitative methods in “mixed methods” designs also gains increasing interest [16].

In contrast to nursing studies, where qualitative and mixed methods are taught at universities in various countries [17], [18], [19], [20], qualitative research courses are hardly part of the medical syllabus [4], [5] and the extent to which they are integrated in the public health syllabus varies widely. Modules teaching qualitative research methods have been implemented in the syllabus of public health – both in Bachelor and Master programmes – at several universities in Germany (e.g. Berlin School of Public Health [21], [22], Leuphana University Lüneburg [22], Jade Hochschule [23]). Some programmes include lectures and seminars focusing on qualitative research methods as mandatory courses, whereas others provide elective courses. According to our experiences, medical students at German universities acquire qualitative research skills in courses external to the medical curriculum (e.g. in interdisciplinary conferences such as Berliner Methodentreffen [24] or discipline-specific seminars) or they learn how to apply qualitative methods during their dissertation phase, when they are appointed with a qualitative research project by a senior researcher.

Teaching and learning about research methods can be challenging and abstract [25]. Qualitative research methods are ideally taught by providing students with the opportunity to familiarize with a qualitative research method by applying it to an empirical research question [25]. This application should take place in a supervised research group [25]. Research-oriented learning offers a suitable framework facilitating this type of learning process [25]. In research-oriented learning, students design, experience and reflect upon a research project which generates knowledge of relevance [26]. Ideally, students embark on all relevant stages of a research process, from developing a question and hypothesis, selecting appropriate methods for data collection and analysis as well as presenting the final results [26]. The Research Skill Development (RSD) Framework provides six facets which guide the conceptualisation and planning of teaching modules which aim at developing student research skills: that students embark on inquiry and so determine a need for knowledge; that students generate needed data using appropriate methodology; that students critically evaluate data and the process to find/integrate them; that students organise information collected; that students synthesise and analyse new knowledge; and that students communicate knowledge and understanding and the processes used to generate them [27]. By going through this process, students develop research skills which they can apply in future research projects [27].

The aim of this paper is to describe the elective qualitative research module and its application at the medical faculty of the LMU Munich. Furthermore, we reflected on possible benefits of teaching qualitative health research to students of public health and medicine (especially with aspiration to write a doctorate thesis using qualitative research methods).

In the summer term of 2016, we implemented the elective module “Qualitative Research Methods in Public Health” (3 European Credit Transfer System (ECTS)) at the medical faculty of LMU Munich. The module was conceptualized and implemented as a joint project of the Institute of Sociology (Hella von Unger (HvU), Dennis Odukoya (DO)), the Institute for Medical Information Processing, Biometry and Epidemiology (IBE) (Michaela Coenen (MC), Lisa Maria Pfadenhauer (LMP)), the Institute for History of Medicine and Medical Ethics (Katja Kühlmeyer (KK)), as well as the Department of Palliative Medicine, Munich University Hospital (Michaela Schunk (MS)). The module was integrated into the master of public health (MPH) programme as it builds upon previously acquired knowledge from module on public health core competencies as well as research skills and as it complements the strong quantitative focus of the MPH programme. Doctoral students enrolled at the medical faculty were also able to participate.

We designed a module for teaching qualitative methods drawing on the RSD Framework and using the approach of research oriented learning. The core and guiding aim of the elective was to teach students qualitative research methods by providing them with the opportunity to conceptualise, plan and implement a qualitative research project. The elective was delivered in three components. These components are

1.

a theoretical component,

2.

a practical component and

3.

a practice period.

The module was taught over five days (Block 1: 2 days; Block 2: 2 days, Block 3: 1 day) during the summer semester, which were followed by a four and two week practice period, respectively. The theoretical component comprised ten teaching units (TU) of 45 minutes each, the practical component comprised 16 TUs while the practice period in which the student groups conducted a research project comprised approximately 60 hours. Figure 1 [Fig. 1] shows the three components, the timeframe as well as the learning topics.

To allow for practice-oriented learning the number of students was limited to a maximum of 16 persons. The team of lecturers consisted of six persons (all co-authors on this paper). In order to align all lecturers involved as well as to ensure coherency in teaching, the concept was developed collaboratively. Before the module was kicked off, we held an initial meeting as well as a debriefing in which the results of the evaluation as well as the personal experiences of all lecturers were reflected, discussed and noted.

As previously described, our module follows the concept of research-oriented learning. This didactic concept was operationalized through theoretical input, instructed practical components as well as a supervised practice period.

The pursuit of the didactic concept was directed at achieving predefined learning objectives. After completion of the course, students should be able to conceptualize a qualitative study, develop and implement a structured interview guide, analyse the collected data and prepare and present the qualitative study and its results. Students should be able to understand the rationale behind qualitative research approaches as well as areas of their application, their strengths and limitations as well as ethical principles. Moreover, they should gain a first insight into mixed method designs as well as their principles and applications.

For the theoretical component of the elective module, we pursued different didactic methods. A broad range of teaching and learning techniques was applied such as seminars, discussions, instructed and guided group work, optional consultation as well as preparatory readings. Thus, a vivid and interactive teaching style was pursued.

Preparatory reading was distributed among the participants before the elective started, comprising both optional and obligatory readings [28], [29], [30], [31], [32], [33], [34]. One of these readings was a paper published by Dubé and colleagues aiming to understand mothers’ decisions to vaccinate or to vaccinate their newborns [30]. This paper served as

1.

example of qualitative methods as applied to the research topic (vaccination) as well as

2.

basis for the quality appraisal.

Two dimensions of reflection formed a critical component in this process: the reflection of normative beliefs held in the field of public health (e.g. on vaccination) as well as the reflection of the researcher herself acting within this field. Self-reflection was initiated in different ways. First, students were asked to write postscripts after they conducted the interviews. Upon return, we started the respective day by inviting each student to reflect on her experiences during data collection and data analysis, respectively. Issues raised by the students were consequently addressed in a moderated discussion.

Alongside the theoretical component, practice-oriented workshops were held in the classroom. These sessions involved guided group work in which student groups developed their own research question and interview guide, participated in an interviewer training, coded the transcribed qualitative data, and analysed mixed method dataset.

The results from these workshops informed the practice periods in which a qualitative research project was conducted. The practical component required the students to conduct qualitative, semi-structured interviews on the issue of vaccination, including the beliefs, attitudes and behaviours towards vaccination of various groups (e.g. young parents, medical professionals, etc.). We chose this topic due to its high relevance in public health [35], [36]. The topic is particularly well- suited for the pursuit of qualitative research, which is underpinned by a qualitative systematic review of 38 qualitative studies in the field of childhood vaccination underpins [37].

During the first block, student groups were established. The groups were formed by the students through shared research interests. Each group consisted of three to four students. In a supervised working session, student groups developed a preliminary research question that was presented to the plenary and subsequently discussed. After the groups decided on the final research question, they developed preliminary interview guides that were partly revised – again by receiving feedback from plenary discussions – before the interviews were conducted.

Each student was required to conduct two semi-structured interviews that would last between 30 and 60 minutes. Students were in charge of the recruitment of the interviewees and the organization of the interviews (time, place). Before the interviews were conducted, the students discussed the participant information and the informed consent with the interviewees. Once written informed consent was given, the students conducted and digitally recorded the interviews. Following the interview, field notes were written to capture the interview context, non-verbal elements and researcher subjectivity.

The digital recordings were transcribed verbatim by the students applying standard transcription rules. Necessary soft- and hardware was provided by the teaching staff (f4transkript; see https://www.audiotranskription.de/english). The students were asked to code and analyse their interviews and to discuss the findings in their group. Qualitative content analysis as suggested by Schmidt was applied [38]. The student groups developed a preliminary category system that was presented at the end of the elective during a final presentation session.

Throughout both practice periods, the student groups had the explicit opportunity to make use of consultation through the teaching staff (LMP, MC). During these practice periods, two fixed dates were offered for consultation and students were offered the possibility to make individual or group appointments as needed. Thus, the two lecturers were constantly available if problems arose.

As evidence of achievement, two aspects were graded:

1.

the final presentation on the research project (group work) and

2.

the portfolio containing interview guides, transcripts, field notes, and the slides of the final presentations (individual work).

The final presentation was held on the last day of the module and lasted 30 minutes. The presentation was followed by a 15 minutes discussion. The portfolio had to be submitted one week after the course was finished.

Both the final presentation and the portfolio were graded according to a tool comprising formal and content criteria. Both the presentation and the portfolio contributed 50% to the overall grade. The criteria according to which the presentations were graded based on a structured tool. This tool has been developed by one of the authors (HvU) and has been previously applied in a similar course. With regards to the presentation, the tool comprises the sections

1.

topic and relevance of the topic (20%),

2.

study design (20%), conduct and analysis (20%), conclusions and open questions (20%) as well as formal criteria (20%).

The criteria for the portfolios were form (10%), completeness (10%), structure (10%), grammar (10%), content and extent of field notes (10%), content and extent of postscripts (10%), adequate use of the interview guide (10%), adequate interviewer behaviour (20%) and indicated reflection (10%). The tool was distributed to the students at the beginning of the elective and was made accessible via the online platform.

Grading was done in a two-step process. The presentations were graded by all members of the research staff who were present during the presentations (LMP, MC, KK, MS, HvU). In the aftermath, the grading for the presentation was discussed during the final meeting. The submitted portfolios were independently reviewed by two members of the teaching staff (LMP, MC). After each lecturer independently graded the portfolio, the final grade was discussed and communicated to the students.

Prior to the beginning of the elective, the teaching staff applied for ethical approval from the Ethics Committee of the Medical Faculty at the LMU Munich in order to approve the student research projects (participant information and informed consent). Students were granted to conduct their research projects on condition to submit final research questions and interview guides upon completion of the projects. Both were submitted for consideration of the ethical board after the student research projects were finished.

We used three approaches to evaluate the module and assess its quality. At the last day, we conducted an open oral feedback round in which we encouraged the students to critically reflect on their learning experience throughout the module. In this session, we referred back to the expectations the students elicited in the first session of the module. In the aftermath, the teaching staff gathered for a debriefing, in which we discussed our experiences and the feedback we received from the students in the feedback session. We also collected first ideas of how to address this feedback in the next year. All statements made during the feedback session and the debriefing were summarized in note form in a document.

Additionally, the elective module was formally evaluated with a structured survey after the elective was finished. This evaluation was conducted anonymously in course of the standard written evaluation by the Master program coordinators. The survey was developed by the coordinators of the MPH program (see Attachment 1 [Attach. 1]). At the end of each term, the coordinators sent out an email with a link to the online survey. The survey comprises nine closed questions and one open field for further feedback. The items comprise frequency of participation in the elective, structure of the concept, consistency of teaching units, clarity of learning objectives, discernibility of central theme, learning effect, academic level of elective and overall appraisal of elective. These questions are answered based on five-point Likert scales. The Likert scales ranged from “1 – very high”, “1 – strongly agree”, “1 – very good” to “5 – very low”, “5 – strongly disagree” or “5 – not sufficient”. The results from the survey were analysed descriptively. The answers to the open question were analysed using summarizing qualitative content analysis (after Mayring [39]).

Of the 16 students who participated in the elective, 14 were enrolled in the MPH programme, one in the PhD Medical Research programme and one in medical studies at LMU. Of the 16 students who participated in the module, 14 were required to obtain evidence of achievement. The other two students (the medical student, a MPH student) participated in order to get theoretical and practical insights into qualitative research methods for the conduct of their master/doctoral thesis. Five student groups were formed. The student groups developed a broad range of research questions. The groups interviewed adults, among these medical students and medical doctors. The groups worked on vaccine scepticism, attitudes of medical students towards vaccines, attitudes of childless adults, attitudes of medical students on doctors towards vaccination in their families, and on the attitudes of the general population on vaccines. All students presented the methodology and results of their work in an oral presentation of 30 minutes as a group exercise and received feedback from the audience. Each of the 14 MPH students also provided a written portfolio including the slides of their oral presentation, interview guides, transcripts of their interviews as well as the field notes and codings, respectively.

Overall, the students were pleased with the setup of the module. In particular, students appreciated the space provided for reflecting on themselves, but also on their professional discipline. Reflecting on the continuum from vaccine acceptance, hesitance up to refusal made the students not only aware of a wide range of subjective perspectives in their interview partners, but also confronts them with their own attitudes towards vaccination. In the feedback sessions, they provided ideas of how the current concept of the module could be further improved. The students expressed that they were overwhelmed by the requirements imposed by the seminar despite having received information material before signing up for the module. Also, they felt that the current number of ECTS was not doing justice to the work load of the module. With regards to timing, the students asked to pay closer attention to the overall curriculum during summer semesters. Some students reported difficulties in selecting an appropriate research question for a qualitative research design.

In the debriefing, the teaching staff felt that more information with regards to the workload and the requirements were required before the students signed up for the module. In order to be able to successfully complete the module, students should also be advised that a sufficient knowledge of German was required. We also reflected on the heterogeneity of the groups. During the first session, we asked students to independently form groups. This resulted in groups with overall different levels of prior knowledge and research skills. While four out of five groups managed to stay on track, one group did not manage to recruit study participants within the given time frame and interviews were conducted relatively late. This resulted in a lower quality of the analysis as well as results presented. The lecturers were aware of these problems and repeatedly offered the team to take advantage of the consultations. This was however only done shortly before presentations were due. We agreed that this might have been prevented by offering more space for individual or group mentoring and decidedto pay closer attention to the individual process of the groups, while being particularly attentive to groups which demonstrated difficulties in the accomplishments.

Nine of the 14 students provided online feedback on the module. Overall, the module was rated as very good (”very goody” n=9), in particular with regards to the discernibility of the central theme (”strongly agree” n=9) and the consistency of the TU (”strongly agree” n=9). Opinions were diverging in terms of the learning effect (”very high” n=5, “high” n=4) and the academic level of the elective (”very high” n=4, “high” n=4, “medium” n=1).

In the open questions of the questionnaire, the students commented on and evaluated their learning experience in their own words. In terms of structure, the students felt the number of credit points (3 ECTS) did not do justice to the work load required to complete the elective. In particular, transcribing and analysing the interviews was considered very time consuming. Also, the dates of the teaching units were subject to criticism since they partly collided with exam preparations.

The students asked for more transparency with regards to the requirements of the course before they had to make a final decision with regards to participation. In terms of content, the students were asking for extended interviewer training, reflection on written field notes, the presentation and discussion of exemplary transcripts as well as an additional session regarding data analysis (“What happens after coding?”).

The students reflected on their experiences in the interviews in their field notes. Several students were challenged by two “clashing worlds of knowledge”, the knowledge that was taught in their studies and the knowledge that was presented by vaccine sceptics. For some students, these worlds were incompatible. One student even felt that he had to step out of his/her role as researcher to engage in consoling the interview partner.

Most students described a positive experience as well as a great learning effect. Some of them appreciated particularly the quality of their lecturers, the choice of literature and the relationship of theory and practice.

We established an elective on qualitative research methods used in public health and medicine, in which students conducted a collaborative qualitative interview study. Compared to all other electives offered in the summer semester, the module gained the highest ratings in the master of public health programme. By pursuing a research-oriented teaching and learning approach, we went beyond teaching information or procedures, with the ultimate goal to achieve deep level learning [26].

As pointed out in the introduction, the ubiquitous lack of training is reflected in various articles expressing concerns with regard to the rigor of the application of qualitative research methods (6, 9), the confidence in its findings [40] and the quality of its reporting [6], [9], [41] [42], [43]. The need for more structured training in qualitative research methods has been recognized in overlapping fields, such as bioethics [44], and relates to a call for a larger integration of scientific skills trainings in the medical undergraduate curriculum in Germany [45]. This measure is supposed to mitigate the low rates of completion of doctoral dissertations at medical schools in Germany [45]. Our course is a first step in addressing this current gaps in curricula of public health and medicine.

Similar research-oriented module are able to endow public health and medical students with the necessary research skills to assess, appraise and conduct qualitative or mixed methods research. Students with first-hand experiences with research methods are expected to be better in the reception of study findings and the reflection on the quality of such studies. As an additional effect, the conduction of qualitative research could improve the communication skills of students and improve their competencies for (self-) reflection as students and practitioners [5].

This module provides students not only with the possibility to reflect on their own opinions and attitudes but also on the normative perspectives held in medicine and public health. Reflection forms an integral part of research-oriented learning [26]. Self-reflection is an integral part of qualitative research methods [25] and has been used as a guiding principle during the research process [46]. In our course, the students explored the perspectives of different groups concerned with vaccination. Vaccination as preventive measure is controversially discussed, while being vaccinated is globally considered the norm in the majority of populations [47].

Nevertheless, the didactic concept has its limitations. The cooperation in groups has previously been described as facilitator to research-oriented learning [26]. As described above, we experienced difficulties in following the curriculum, while being attentive to the different needs expressed by the groups. For this reason, students are now mandatorily required to submit their interview guides as well as the transcripts within a given time frame, followed by attempts to balance the composition of more heterogeneous groups.

As the previous example has demonstrated, it is critical to provide a coherent structure and time-line of the course that allows the students to receive feedback from their fellow students as well as the teaching staff [26]. As the evaluations have shown, we did not provide sufficient learning opportunities with regards to the analysis of the acquired data. For this purpose, we adapted the syllabus of the elective by adding an additional course day between the second and third block. On this day, we will provide hands-on support during data analysis in form of small research-analysis-groups where the students have to opportunity to reflect upon the applied analysis strategies. This day will be held in the format of a workshop. To reduce the workload, we will introduce a limit to the mandatory number of interview minutes to be transcribed verbatim to 60 minutes.

In contrast to problem-oriented learning, the students selected their own topic of interest in the area of vaccination. As students of public health and medicine, all students were acquainted with the topic through previous teaching modules. Additional theoretical input was provided during the introductory session. However, we did not require the students to conduct a literature review prior to selecting a question. We will therefore provide more time for the process of constructing a qualitative research question in the future, e.g. by adding a literature research task in the following courses and reserve time for feedback.

We experienced that students were overwhelmed by the requirements imposed by the seminar despite having received information material before signing up for the module. A precise and transparent outline of the requirements is considered crucial to the success of a research-oriented teaching module [26]. We will therefore implement an orientation session in which we will introduce the didactic concept to the students before they have to make a final decision about their participation. Furthermore, the students will now be awarded with 6 instead of 3 ECTS for the successful participation in the module to adequately account for the workload.

Research-oriented teaching is also challenging for the research staff, in particular with regards to the necessity of close supervision, guidance and consultation [26]. In principle, we were able to facilitate this through a high student-lecturer ratio having a pre-specified maximum number of 16 participants as well as six teaching staff members that ensured this supervision. Despite this relatively high rate, the timeslots where students benefitted from individual feedback were limited. Therefore, the session where the analysis method is reflected upon will be held in the project groups with a tutor for each group.

We are fully aware that this elective module does not do justice to the variety of methodologies of qualitative research. We focused on semi-structured interviewing at the expense of other methods of data collection (e.g., narrative interviews, focus groups, participatory observation) and analysis (e.g. grounded theory methodology, phenomenology, narrative analysis, hermeneutics) available in the field of qualitative research. In contrast to qualitative research taught in other disciplines, qualitative health research requires specific skills and produces specific outcomes [28]. By selecting methods commonly used in the field of public health [48], [49], we aimed at providing a first experience with a whole research process. Since the students were not able to select the method for data collection and data analysis themselves, as it would have been the ideal case in research-oriented learning [26], we asked them to critically reflect upon the methods of data collection and data analysis.

This elective module has been developed by experienced teaching staff from various disciplines. By combining different disciplinary perspectives, the module shows a good transferability to other courses of study within the health field. The data collection and analysis methods used in our course (interviews and qualitative content analysis) might appeal to research skills educators in related fields such as medical education or bioethics. With the ongoing transformation of traditional medical doctorate programs, where the doctorate candidate is “learning by doing” during mentorship of his supervisor, into structured programs that require the doctorate candidate to complete research skills courses might lead to the implementation of more structured research skill trainings in the future (e.g. Munich Medical Research School [50]). Lecturers in disciplines outside medicine, such as nursing, psychology [51] or occupational therapy [52] might consider using the general structure of this course but adapt specific aspects to their preferred methodology (e.g. phenomenological analysis). In order to further tailor the module, a topic of high relevance to the respective discipline should be selected.

We plan to transfer the module into a blended learning course (inverted/flipped classroom). We will integrate online teaching in the module through which we want to convey the theoretical knowledge of qualitative research methods to our students [53], [54]. Thus, we hope to increase the time where we foster the assimilation and implementation of the knowledge and to create more opportunities to provide mentoring during the research methods. To transform the module, we were awarded with a grant by a programme which is dedicated to train teaching staff and support them in implementing individual project ideas (Multiplikatoren-Programm (Lehre@LMU) [55]).

The evaluation, the evidence of achievement and our personal experiences demonstrate that the delivery of this research-oriented module on qualitative research methods can be considered as successful in conveying an overview over qualitative methods, their theoretical underpinnings as well as practical applications in the field of public health and medicine. It extends the methodological portfolio taught in public health and medicine at the University of Munich and thus endows students with the skills to address future research questions with the most appropriate methods. The cognitive, emotional and social experience of the research cycle reaching from the initial curiosity, research design and structuring, the emotions associated with going through a research process as well as being able to provide an answer to the question of interest, might be considered of particular value for learning.

We would like to thank the 16 highly motivated students who actively participated in the module and gave us their extensive feedback. Also, we would like to thank Prof. Dr. Ulrich Mansmann (IBE, LMU), PD Dr. Eva Rehfuess, Dr. Sabine von Mutius as well as Karin Seeger for their support in the conceptualization, planning and implementation of this module.

The authors declare that they have no competing interests.