| Abstract|| |
Background: Qualitative research methods (QRMs) bear a critical role in psychiatry as they explore the phenomenology of psychiatric illness and its sociocultural dimensions. However, there is limited evidence regarding its use in psychiatric research in India.
Aim: This study, under the aegis of mapping qualitative health research in India initiative, attempted to landscape the use of QRMs in psychiatry and elicited expert opinion on its potential, perceived quality, and scope for improvement.
Materials and Methods: We reviewed studies using qualitative methodology published in the Indian Journal of Psychiatry (IJP) and the abstracts presented at the Annual Conference of the Indian Psychiatric Society (ANCIPS) between 2010 and 2019. Titles and abstracts were screened and shortlisted; full-text articles were checked to identify the relevant ones. In addition, ten experts comprising psychiatry journal reviewers, editors, and conference scientific committee members were interviewed to elicit their views and suggestions.
Results: Out of 356 papers published in IJP between 2010 and 2019, only 12 papers used QRMs: five qualitative and seven mixed methods. Out of 2297 abstracts published between 2010 and 2019 in ANCIPS, only 28 had used QRMs, consisting of 20 qualitative and eight mixed methods. The findings reveal that qualitative research is still an understudied domain in Indian psychiatry with a substantial need for rigor and quality.
Conclusions: To catalyze the use of qualitative research in Indian psychiatry, continuing medical education programs through workshops or webinar mode need to be imparted. These trainings should aim at building skills on qualitative study design, data collection, analysis, and writing.
Keywords: India, mapping, mental health, psychiatry, qualitative research
|How to cite this article:|
Mahapatra P, Sahoo KC, Jitendriya P, Samal M, Pati S. Qualitative research methods in psychiatry in India: Landscaping the terrain. Indian J Psychiatry 2021;63:5-14
| Introduction|| |
Globally, psychiatric disorders are recognized as one of the priority areas in health research and policy, and it is also included in sustainable development goals. In India, more than 197 million people are affected by psychiatric disorders of varying severity, a majority of them having depression or anxiety disorders. The proportion of these disorders to the total disease burden in India has almost doubled in the last three decades, and the increase is more prominent among adults. This rising trend calls for an increased emphasis on research in psychiatry.
Qualitative research methods (QRMs) are widely acknowledged approaches used in psychiatric conditions to know the phenomenology of the illness and its social and anthropological dimensions, which include stigma, traditional beliefs and practices, and care-seeking behavior. It also explores the effectiveness of the health system and programs, leading to policy changes. Qualitative studies generate contextualized understanding of these phenomena by collecting data from all the possible stakeholders: patients, caregivers, service providers, managers, and key decision-makers. It relies on the collection, analysis, and interpretation of “language data” in the form of interviews and written texts to generate hypotheses. The use of QRMs is gradually increasing in psychiatric research, and there are several principles and methods related to its use in psychiatry.,
In India, there is substantial variation in the prevalence and manifestations of psychiatric disorders across regions, genders, occupations, age groups, and ethnicity. Similarly, differences exist among peoples' lay beliefs and understanding of mental health disorders. These have an impact on the care-seeking and health services utilization., Information generated from qualitative research can be appropriate for developing interventions, policy, and implementation of innovations on mental health issues.,, Although QRM has a significant role in psychiatric research in a country like India, there is little information available on how it is currently being used in Indian psychiatry.
Journal articles and conference presentations can be a surrogate indicator of the adoption and familiarity of any research method in a discipline. Hence, to better understand the current state of qualitative research in Indian Psychiatry, we planned to carry out an evidence mapping exercise. In this study, we explored the proceedings of the Annual Conference of the Indian Psychiatric Society (ANCIPS) between 2010 and 2019 for research presentations with qualitative methodology. We also attempted to map the articles with QRM published in the Indian Journal of Psychiatry (IJP) during the same period. Furthermore, we interviewed experts to elicit their views on the findings and suggest measures to enhance qualitative research in psychiatry in India.
| Materials and Methods|| |
This study is a part of a larger initiative mapping of qualitative health research in India to landscape the use of qualitative research techniques in clinical and paraclinical and allied health professional disciplines such as physiotherapy, pharmacy, and AYUSH. Since the field of psychiatry and mental health has substantial impetus to harness QRMs, we decided to carry out our first qualitative health research mapping exercise in the discipline of psychiatry.
We used an explanatory mixed-method approach. The study was initially based on secondary data – a systematic review of qualitative studies published in IJP and ANCIPS, and the explanation of these findings was sought through primary data in the form of interviews from leading academicians, psychiatrists, and journal editors.
We reviewed conference proceedings of the ANCIPS and research papers published in the IJP during the past decade (2010–2019) for the use of QRM. The IPS, with over 7000 members, is the largest society of mental health professionals in India. It works for the promotion of education, training, and research in psychiatry. It works for the promotion of education, training, and research in psychiatry. The ANCIPS is the annual event of the IPS having workshops, symposiums, and free papers that are attended by faculties and students. The IJP is the official journal of the IPS that publishes the papers presented at the ANCIPS. These, along with the published articles, were obtained from the home page of the journal.
After consultation with experts, we developed a list of terms indicating qualitative research. These included “phenomenological,” “perception,” “perspective,” “opinion,” “view,” “explanation,” “focus group discussion,” “in-depth interview,” “observation,” “exploration,” “qualitative,” “narrative,” “exploratory,” “explanatory,” “convergent,” “believe,” “mixed method,” “framework analysis,” “content analysis,” “grounded theory,” “thematic analysis,” and “interpretative phenomenological analysis.” We used the above terms to screen for qualitative and mixed-method studies in the oral paper presentations at the ANCIPS and the original research articles of IJP. First, the titles were looked at, followed by the abstracts. Furthermore, we also checked the full-text articles from the IJP for their methodology.
Two predecided checklists were prepared separately for conference proceedings and published articles. After entering the details of the studies in Excel sheets, we conducted a descriptive analysis. The abstracts and published articles were shortlisted by two authors independently to include the mixed-method and qualitative studies, and these were further reviewed and cross-checked by a third author. All the studies using qualitative methods were considered, including those with mixed-methods research. In the conference proceedings, we excluded the abstracts of oral papers showing incomplete results.
To complement our findings, we contacted ten experts, members from the scientific committee of ANCIPS, and the editors and reviewers of the IJP over the phone. Through semistructured interviews, views and opinions related to QRMs were elicited. The topics discussed included first, the current status of QRMs in Indian psychiatry; second, information related to the submission and selection of QRM papers or articles to ANCIPS or IJP; and the challenges for journal editors and reviewers. Their recommendations were sought. The discussions were digitally recorded transcribed, coded with MAXQDA software (MAXQDA Analytics Pro 2020, VERBI GmbH Berlin), and analyzed using content analysis.
The Institutional Ethical Committee of Kalinga Institute of Medical Sciences, Bhubaneswar, approved the study. We contacted the key informants over email and telephone, explaining the purpose of the study, and obtained their consent. Anonymity and confidentiality of the interviewees were maintained.
| Results|| |
Findings from Indian Journal of Psychiatry publications and Annual Conference of the Indian Psychiatric Society presentations
Out of 356 published articles in the IJP during 2010–2019, only 12 studies (3.4%) used QRMs: five were only qualitative and seven used mixed methods.
Out of 2297 abstracts published from ANCIPS proceedings during the same period, a total of 28 published abstracts (1.2%) used QRMs: 20 qualitative and 8 used mixed methods. In the first 5 years of the decade under study, 2.7% of the published articles (four out of 148) had a qualitative methodology compared to 3.8% (eight out of 208) of them over the following 5 years. Similarly, in the first 5 years of that decade, 0.7% of the published abstracts of ANCIPS (six out of 913) had a qualitative methodology compared to 1.7% of them over the following 5 years. The detailed mapping of qualitative psychiatric research in published abstracts of ANCIPS and articles in IJP during 2010–2019 is presented in [Table 1].
|Table 1: Mapping of qualitative psychiatric research published in the Indian Journal of Psychiatry and Annual Conference of the Indian Psychiatric Society proceedings during 2010-2019|
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It was observed that although limited numbers of studies using QRMs were published in IJP (n = 5), all the studies followed standard qualitative research protocol. These studies used qualitative interviews using a semistructured guide for the data collection. Mostly, the studies were conducted among patients, caretakers, and family members. Four studies were focused on mental health behavior and one on treatment delay. The detailed design, data collection methods, participants, settings, institute, and major domain of the qualitative studies published in IJP are described in [Table 2].
|Table 2: Design, data collection methods, participants, settings, institute, and major domain of the qualitative studies published in the Indian Journal of Psychiatry|
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In [Table 3], the details of design, data collection methods, participants, settings, institute, and major domain of the qualitative abstracts published from ANCIPS are presented. Out of 20 published abstracts, two used focus group discussions (FGDs), ten interviews (in-depth, semistructured, key informants), six both interviews and FGDs and one observation, and one published material in print media. Major psychiatric disorders found in these abstracts were related to anxiety, depression, schizophrenia, alcohol dependence, and smoking. Psychosocial impact or other medical illnesses such as cancer were also studied. Attitude, beliefs, and behavior and health-seeking behavior were explored in these studies. The studies used QRMs to find the consequences of psychiatric illnesses or the challenges in health care. Other issues presented include the role of media in psychiatry. Many of the abstracts did not have clarity in study design or a standard protocol. Sometimes, the analysis of data was not done adopting standard qualitative approaches.
|Table 3: Design, data collection methods, participants, settings, institute and major domain of the qualitative studies published in Annual Conference of the Indian Psychiatric Society conferences proceedings|
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In [Table 4], mixed-method studies published in IJP are presented. It was observed that all seven studies used convergent parallel mixed-methods design. The studies were conducted in India, and the major psychiatric issues addressed pertained to reproductive and adolescent health, suicide, child abuse, and autism. It also included psychiatric education and community mental health. The studies explored care challenges, care seeking, and capacity building. Similarly, [Table 5] represents mixed-method abstracts published in the proceedings of ANCIPS. All eight abstracts used convergent parallel mixed-methods designs. The major psychiatric disorders studied were schizophrenia, bipolar mood disorder, opioid dependence, and autism. The issues explored in them were perception toward the above illnesses and their care-seeking pathway.
|Table 4: Design, data collection methods, participants, settings, institute, and major domain of the mixed methods studies published in the Indian Journal of Psychiatry|
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|Table 5: Design, data collection methods, participants, settings, institute and major domain of the mixed methods studies published in Annual Conference of the Indian Psychiatric Society proceedings|
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The quality assessment of the five qualitative studies published in the IJP was assessed using the consolidated qualitative research reporting assessment tool [Table 6].
|Table 6: Quality assessment of the qualitative studies published in the Indian Journal of Psychiatry using consolidated criteria for reporting qualitative research assessment tool|
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Experts' experiences and views
After analyzing the interviews with experts, five major categories were identified: (1) current position of QRMs in India, (2) conference presentations and journal submissions, (3) current training and orientation, (4) challenges for editors and reviewers, and (5) promoting QRMs in psychiatry research.
Current position of qualitative research methods in India
Many experts expressed that know-how in any kind of research is increasing among teaching faculties compared to the past. However, even with this trend, only a few of them can carry out studies with QRMs. Two of the experts who also teach in postgraduate institutes expressed that most faculties have lesser expertise in qualitative than quantitative research. Although they know about the methods, they have lesser skills when it comes to teaching or research. It is treated with either suspicion or with awe. Many psychiatrists, they said, just write off the entire qualitative research as a method.
”Previously there was even less understanding about research methodology itself. Now that has improved among the faculty. I must say, practically, very few understand qualitative research.” [E-8]
Conference presentations and journal submissions
Experts who worked on the selection of ANCIPS papers reported that the number of QRM submissions was lower, while many of them were mixed-method research – very few were purely qualitative. According to their opinion, the research topic, method, and availability of time slots were considered and QRM papers had equal chances of being selected. Some of them added that some qualitative research attracts more inquisitiveness when discussed for selection and generates more interest. All experts with experience as editors or reviewers indicated that the number of articles received with QRMs was very few as compared to those with quantitative methods. One of them expressed that few researches are being done having qualitative methods, and maybe fewer of them appear in publications. Another expert said that it was only 5% of the usual research published in the common popular psychiatric research journals in India. However, journals are receiving an increasing number of submissions and are publishing more QRM papers than before. According to one respondent, many of the papers submitted with QRM come from a few reputed institutions, and a good proportion of them is received from allied branches, such as clinical psychology and psychiatric social work.
”There is hardly any qualitative research. I don't know how much it is done but it doesn't figure in publications.” [E-5]
Current training and orientation
Some of the respondents who worked as teaching faculties said that there is no specific training for medical postgraduate students in QRM, this is part of the research methodology module in the curriculum. One of them suggested that QRM should be included in the postgraduate curriculum. According to him, during their academic training in the weekly journal club discussion, students mostly analyse quantitative articles. Training that develops an eye for understanding or interpreting QRMs is limited. Three of these experts reported that few students in their MD psychiatry thesis have begun QRM studies, but these are mostly mixed-method designs and there are hardly any purely qualitative studies. Some of them reported that there were few specific training programs for QRM. According to them, qualitative research involves a lot of hard work in the form of interviewing, transcription, and analysis, and therefore practical training is very important. On the contrary, much less time was spent teaching QRMs.
”As long as we don't have right mentors who can guide the students to carry out QRMs, it may be difficult to progress further.” [E-3]
Challenges for editors and reviewers
Experts with editorial experience reported that limited articles in QRMs had been submitted to journals and minimal articles had followed the appropriate checklist. One of them noted that, over the last 2 years, there has been an increasing trend in the submission of QRM articles, but most of them are mixed-method articles, with very few being purely qualitative. They noted that a limited number of researchers were also pursuing and reviewing qualitative articles. It was difficult for them to find adequately trained reviewers to assess the quality of qualitative research and to examine the appropriateness of the methods. As they see it, many submitted papers have just conducted QRMs without adequate knowledge of their rationale and methodological accuracy. They all agreed that clarity of the process is needed in the design, development of the tools and analysis, and interpretation of the findings.
”We're getting a few QRMs papers; obviously, we're not getting quality papers; the researchers are not very comfortable or conversant with QRMs.” [E-7]
Promoting QRMs in psychiatry research
Many experts believed that QRMs have their place in the research scenario because certain phenomena – the experience of patients, caregivers, and providers – are difficult to address quantitatively. They expressed that there was a substantial need to conduct, interpret, and publish the findings from a qualitative perspective, and these findings need to be translated into clinical and theoretical applications. Some experts proposed that there was a need to increase the capacity and competence in QRMs. They suggested that proper workshops are crucial for orientation and raising awareness and that hands-on training in QRM is essential because it takes a lot of effort to have an understanding and expertise.
| Discussion|| |
Qualitative research in psychiatry is yet to make its mark in India, as evidenced by published conference presentations and research papers. Not much is known about the extent and use of QRMs in psychiatry in India. To our knowledge, this is the first mapping exercise exploring the use of QRMs in Indian psychiatric research, reviewing conference proceedings, publishing papers, and obtaining expert opinions. The findings help identify areas for intervention to catalyze qualitative research in the practice of psychiatry.
There is an increase in qualitative research in recent years, but traditional methods continue to dominate in Indian psychiatry. Our findings reveal that only a few articles published in IJP in the last decade (3.4%) used QRMs. Most had a mixed-methods approach and limited articles had a purely qualitative methods.,,,, Similarly, the papers presented at ANCIPS had few researches using qualitative methodology (1.3%). Analyzing further, it was found that the published articles and conference abstracts showed a rising trend when those from the second half of the decade are compared with the first half. This reflects an increasing interest worldwide in the use of QRMs in psychiatric research, given its usefulness in exploring aspects not covered by quantitative research., Qualitative research is often featured in prominent international journals. The journals publishing qualitative research in mental health includes Biomed Central group (psychiatry, public health, health services research, research notes, women's health, family practice, complementary and alternative medicine), and other psychiatric journals like – International Review of Psychiatry, The Canadian Journal of Psychiatry, Australian and New Zealand Journal of Psychiatry and The British Journal of Psychiatry, to name a few.,,, Despite the increase in interest in QRMs, much more needs to be done to utilize the approach in Indian psychiatry.
The present review revealed that a phenomenological approach to qualitative methods is mainly used to study psychiatric disorders. The disorders covered are mainly schizophrenia; autism and intellectual disability; geriatric health issues; tobacco, alcohol, and drug dependence; and psychological aspects of systemic illness such as cervical cancer. These studies also explored issues such as health system challenges, psychiatry teaching and training, and the role of media and mental health. Different approaches to qualitative research can be utilized to inform us in various aspects of an illness. Ethnography, phenomenology, and grounded theory are major approaches in qualitative study designs. While ethnography explores culture groups, phenomenology deals with the psychosocial aspects by examining the lived experience of individuals. A grounded theory approach is used to develop theories grounded in real-world observations. Phenomenological approaches studying psychiatric disorders involve patients, their caregivers, and care providers or any stakeholder, exploring their views and experiences concerning a phenomenon. It tries to analyze their behavior and responses in the face of illness., Barriers to care vary in different settings and it can be best studied by qualitative research., Among the other uses in the field of psychiatry, QRM provides the most context-specific answers when we want to develop acceptable healthcare services, effective policies, and programs in a specific setting. It also can shape medical education and training by developing effective ways to teach psychiatry. Although qualitative studies have the potential to inform on various aspects of psychiatric care, our findings have shown that QRMs are yet to be used to their true potential in Indian psychiatry research.
Most of the published research followed appropriate qualitative methods. All the studies published in IJP followed standard qualitative research guidelines. However, of the studies presented in ANCIPS, only a few followed standard QRMs guidelines. The studies using mixed methods were mainly parallel convergent design. Although quantitative research is more likely to get published, qualitative research, when properly carried out, is equally likely to be published.,, Experts who were interviewed emphasized the need to design and present methodologically sound studies to get them published. Hence, to increase the presence of qualitative research in psychiatry journals, the submitted papers should convey a clear methodology, analysis, and presentation.
Most of the experts interviewed were of the view that few qualitative researches are being carried out in Indian psychiatry as there are fewer researchers adequately trained in QRMs. The availability of fewer training opportunities leads to a few trained in qualitative research and that results in less published papers. The scarcity of qualitative research may also be due to its recent appearance in Indian psychiatric studies and the fact that qualitative methods have not yet been accepted by the scientific community as an alternative or complementary form of research. Qualitative research requires complex skills in the design, execution, analysis, and presentation of information. This includes the ability to think qualitatively, to perform skills such as interviewing, transcription, coding, and writing findings., A culture or ethos of QRMs in psychiatry is needed to accelerate the learning process. This calls for greater emphasis on methodological training, including teaching curricula and applied research, starting from postgraduate studies in psychiatry.
The quality evaluation of the studies suggests that the studies reported in the IJP have followed a defined standard protocol. However, few studies presented in the ANCIPS have adopted a standardized protocol in which only the design portion of the research was dealt with. The authors found that the ANCIPS did not publish the full manuscript; rather, only abstract was published. The authors propose that if ANCIPS publishes short qualitative papers in the range of 1000 to 1500 words instead of only abstracts, the content would be improved in terms of clarity and quality and the results could be used for practice and policy recommendation.
To increase the credibility of this systematic synthesis, a research triangulation approach was followed – information was collected from various sources and mixed-method approaches were used for data collection and analysis. Besides, the authors come from a variety of educational and professional backgrounds, which broadens the analysis. The limitation of this study was that although many journals publish psychiatric research in India, only publications in the IJP were considered as it is the official journal of the IPS. Some of the researches carried out in India could have been published in international journals, which were not examined. Second, in our study, we have considered only ANCIPS, the conference of IPS. However, we believe that our study findings in India can inform on the present landscape of a QRM in psychiatry.
| Conclusions|| |
The findings of the study reveal that qualitative research is an unexplored area of clinical psychiatric in India. The prevailing paucity of such research in psychiatry and the absence of focused training programs contribute to the limited number of professionals well versed in qualitative research. Capacity building programs should be carried out in the form of CME, workshops, or webinars to enhance the acceptance of qualitative research in psychiatry. In future, we intend to undertake an assessment of the curriculum and teaching program for postgraduate degree courses in psychiatry for the inclusion of qualitative research. We further propose to explore the perspectives of faculty and residents of psychiatry on their perceived necessity and competence to undertake qualitative research in their practice-based research. To obtain a more comprehensive landscape, we would complement the existing findings by encompassing all relevant journals dwelling on Indian psychiatric scenario.
We record our deep gratitude to Dr. Sujit Sarkhel, Associate Professor, Institute of Psychiatry, Kolkata, for facilitating the study at key stages. We sincerely thank the Indian Psychiatric Society for their kind support. We are also thankful to Dr. Banambar Sahoo, Library and Information Officer, ICMR-RMRC, Bhubaneswar, for making available the necessary articles for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Regional Medical Research Centre, Indian Council of Medical Research, Chandrasekharpur, Bhubaneswar - 751 023, Odisha
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]