Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons
Tom Parkman, Jo Neale, Ed Day & Colin Drummond (2017) BMC Health Services Research 17:140.
The November Qualitative Methods Journal Club was hosted at the Society for the Study of Addiction’s PhD Symposium. The QMJC attracted 12 students with a variety of PhD topics and from a range of backgrounds, including practising clinicians. We discussed the above titled paper, published online in BMC Health Services Research.
Our discussions focussed on the use and application of conducting qualitative research with heavy drinkers who frequently attend hospital accident and emergency departments. Overall, attendees felt that the paper was well written and easy to read. They identified various benefits of using a qualitative approach for the study. Notably, qualitative interviews obtained detailed and in-depth views, perceptions, and experiences into an unexplored area that would be impossible to obtain using quantitative research methods.
The introduction succinctly presents the background and rationale for the study – significant resources are spent on a relatively small number of patients who repeatedly present to EDs with alcohol-related harms, yet we do not know why they attend. It draws on international literature to highlight the relevance of the issue for national and international readers. Andersen’s Behavioural Model (BM) of Health Services Use – a theoretical framework used by the authors to understand factors that contribute to repeated ED attendances – is also clearly explained, though some students suggested that more information could have been provided on why the model was chosen, including why it was selected over similar models.
The methods are helpfully broken down into study design and setting, selection of participants, data collection, and analysis. Attendees welcomed that the research took place in 6 different hospitals in London, rather than a single hospital. Whilst students recognised why ED staff were used to identify eligible participants, they thought that the limitations of this recruitment approach could have been mentioned.
We liked how the authors provide a considered understanding of some of the practical and ethical issues they faced in researching this population (e.g. how intoxication influenced the ability to provide informed consent and when and where to conduct interviews). Students with clinical and/ or research experience of alcohol issues praised the flexibility and humanity of the researchers.
The authors give a transparent description of the coding and analytical process, including how themes were mapped to the BM. Attendees welcomed the application of the BM as a conceptual model to guide the analysis. This links into the findings, which are organised into the 3 predictive factors of the BM (predisposing, enabling, and need). The findings presented appear balanced and nuanced – they consider the breadth and depth of the data (e.g. by providing positive views of ED staff and ED visits alongside less positive experiences).
Contextual information is provided on the participants’ physical and mental health, social circumstances, and alcohol use which highlights their vulnerability and helps to situate and explain the findings. The authors skilfully draw on short verbatim quotations from various participants to support their analyses and refrain from overusing quotations.
The discussion reminds the reader of the aim of the study and coherently summarises the main reasons why people repeatedly attend EDs for alcohol-related reasons. We are reminded of the value of using the behavioural model as a conceptual framework. In line with the aims and scope of BMC Health Services Research, the authors clearly identify implications of the study findings. However, some QMJC attendees working in clinical settings challenged the suggestion that frequent ED attenders could be signposted to primary care and specialist addiction services to reduce repeat attendances at ED on the grounds of practicality and restricted resources. As the study was conducted in London, the authors caution readers from inappropriately drawing empirical generalisations from the data.
The study conclusion overviews the main findings and highlights the important role ED staff play with patients who repeatedly attend EDs for alcohol-related reasons.
Dr Charlotte Tompkins and Dr Samuel Parker, on behalf of the SSA PhD Symposium Qualitative Journal Club.
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Leung, L. (2015) Validity, reliability, and generalizability in qualitative research. Journal of Family Medicine and Primary Care 4(3): 324–327.
Neale, J. (2016) Iterative categorization (IC): a systematic technique for analysing qualitative data. Addiction 111(6): 1096-106.
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.