Rachel Baker

We are to propose that along Q-technique lines it is often possible to discover complex facts, of the kind usually regarded as inferences, by previous study of relatively few cases only. They can thereupon be counted, if need be, by using an appropriate questionnaire and large-sampling techniques (Stephenson, 1953, p. 190). Abstract. Q methodology has been employed to great effect in studies addressing questions which are qualitative in nature. Techniques associated with Q methodology can also be used to explore quantitative research questions. Where a number of shared accounts around a particular topic have been identified and described using Q methods, it may also be of interest to examine the extent and distribution of those views. Such quantitative questions can be explored using Q-survey methods. In this paper we describe a range of approaches to such Q surveys and identify areas of future methodological development and research.

This study explored mid-adolescents’ views and experiences of socio-ecological influences 15 on their drinking practices in order to help inform the development of interventions to reduce 16 alcohol-related risk. We conducted 31 in-depth interviews with young people aged 13-17 in North 17 East England. Verbatim interview transcripts and field notes were coded systematically and 18 analysed thematically, following the principles of constant comparison. We adopted Bourdieu’s 19 idea of social game-playing and elements of his conceptual toolkit (particularly habitus, capital and 20 field) during analysis. Analysis yielded three intersecting themes: (1) ‘drinking etiquette’: conveying 21 taste and disgust; (2) ‘playing the drinking game’: demonstrating cultural competency; (3) ‘hidden 22 habitus’ – the role of alcohol marketing. Our work demonstrates that there is a nexus of influential 23 factors which come together to help shape and reinforce mid-adolescents’ behaviour, norms and 24 v...

This study explored mid-adolescents' views and experiences of socio-ecological influences on their drinking practices in order to help inform the development of interventions to reduce alcohol-related risk. We conducted 31 in-depth interviews with young people aged 13-17 in North East England. Verbatim interview transcripts and field notes were coded systematically and analysed thematically, following the principles of constant comparison. We adopted Bourdieu's idea of social game-playing and elements of his conceptual toolkit (particularly habitus, capital and field) during analysis. Analysis yielded three intersecting themes: (1) 'drinking etiquette': conveying taste and disgust; (2) 'playing the drinking game': demonstrating cultural competency; (3) 'hidden habitus'-the role of alcohol marketing. Our work demonstrates that there is a nexus of influential factors which come together to help shape and reinforce mid-adolescents' behaviour, norms a...

The past decades have seen advances in cancer treatments in terms of toxicity and side effects but progress in the treatment of advanced cancer has been modest. New drugs have emerged improving progression free survival but with little impact on overall survival, raising questions about the criteria on which to base decisions to grant marketing authorizations and about the authorization procedure itself. For decisions to be fair, transparent and accountable, it is necessary to consider the views of those with relevant expertise and experience. We conducted a Q-study to explore the views of a range of stakeholders in France, involving: 54 patients (18 months after diagnosis); 50 members of the general population; 27 oncologists; 19 healthcare decision makers; and 2 individuals from the pharmaceutical industry. Three viewpoints emerged, focussing on different dimensions entitled: 1) 'Quality of life (QoL), opportunity cost and participative democracy'; 2)'QoL and patient-c...

Tonsillectomies for children with recurrent sore throat are common. There is a perception amongst medical professionals that parents are eager for surgical intervention but the parent/child perspective is overlooked in the literature. This study aimed to identify parent/child experience of recurrent sore throat. The study was qualitative, using grounded theory approach to data collection/analysis. Semi-structured, in-depth, interviews were conducted with 12 dyads of children (aged 4—16) and their parents, attending two Ear, Nose and Throat outpatient clinics held at a hospital in North East England, referred by their General Practitioner for recurrent sore throats. Analysis revealed recurrent sore throats significantly affected the families’ quality of life. Families felt the need for antibiotics and tonsillectomies although parent and child were not always in agreement over their choice of treatment. Families felt empowered when the health care system showed some flexibility, such ...

Financially vulnerable, low-income individuals are more likely to experience financial exclusion as they are unable to access financial services that meet their needs. How do they cope with economic instability, and what is the role of social networks in their coping strategies? Using financial diaries, we explore the day-to-day monetary transactions (n = 16,889) of forty-five low-to-moderate income individuals with restricted access to mainstream lending in Glasgow, UK, over a six-month period. Our sample includes users of microcredit and financial advice, as well as nonusers of these services. Findings reveal that informal lending to avoid the pernicious effects of short-term illiquidity was pervasive among these individuals. However, taking informal loans often strains valuable social capital and keeps people from building up a formal credit footprint. Our findings suggest that financially vulnerable populations would benefit from policies that focus on alternative financial mech...

Q nlethodology has been ell1ployed to great effect in studies addressing questions which are qualitative in nature. Techniques associated with Q ll1ethodology can also be used to explore quantitative research questions. Where a nunlber of shared accounts around a particular topic have been identified and described using Q methods, it 1nay also be of interest to examine the extent and distribution of those views. Such quantitative questions can be explored using Q-survey methods. In this paper we describe a range of approaches to such Q surveys and identify areas of future nlethodological developnlent and research.

This paper focuses on the role of actors that operate outside formal health systems, but nevertheless have a vital, if often under-recognised, role in supporting public health. The specific example used is the 'social enterprise', an organisation that seeks, through trading, to maximise social returns, rather than the distribution of profits to shareholders or owners. In this paper we advance empirical and theoretical understanding of the causal pathways at work in social enterprises, by considering them as a particularly complex form of public health 'intervention'. Data were generated through qualitative, in depth, semi-structured interviews and a focus group discussion, with a purposive, maximum variation sample of social enterprise practitioners (n = 13) in an urban setting in the west of Scotland. A method of analysis inspired by critical realism - Causation Coding - enabled the identification of a range of explanatory mechanisms and potential pathways of causat...

Governments across Europe are required to make decisions about how best to allocate scarce health care resources. There are legitimate arguments for eliciting societal vales in relation to health care resource allocation given the roles of the general public as payers and potential patients. However, relatively little is known about the views of the general public on general principles which could guide these decisions. In this paper we present five societal viewpoints on principles for health care resources allocation and develop a new approach, Q2S, designed to investigate the extent to which these views are held across a range of European countries. An online survey was developed, based on a previously completed study Q methodology, and delivered between November 2009 and February 2010 across nine countries to 33,515 respondents. The largest proportion of our respondents (44%), were found to most associate themselves with an egalitarian perspective. Differences in views were more...

The valuation of health in monetary terms can be estimated by observing real choices or by eliciting willingness to pay (WTP) through presentation of hypothetical choices to respondents (contingent valuation). Contingent valuation is commonly used in other areas of the public sector and its use is growing in health. In this article, the authors outline the rationale for such monetary valuation via WTP measurement before going on to discuss challenges associated with different approaches and provide examples from some recent case studies of how such monetary measurement has been achieved.

The work of NICE in the UK and equivalent health technology assessment bodies in other European countries, has placed the emphasis on cost per QALY as a measure of the efficiency of health care interventions. Whilst the techniques of cost effectiveness analysis are increasingly sophisticated, two fundamental questions remain. Firstly, what is the value to society of a QALY? In other words can a cost effectiveness threshold, above which interventions are deemed inefficient and below which they are considered efficient, be derived from values given by members of the general public. And second, is a QALY a QALY a QALY? That is, are QALYs gains' to different groups of beneficiaries valued differently? In this paper we focus on the second of these questions. Debate in the health economics literature suggests there are factors, other than efficiency, that may be important in valuing health gains, for example the age of the recipients of health care, or whether QALY gains are life saving or quality of life enhancing. Using Q methodology we explore the points of view of a sample of members of the UK general public. Based on focus group discussions a set of statements (46) were derived around issues of priority setting and the relative value of health gains. These statements were printed onto cards and respondents undertook card sorts, placing cards onto a 'sorting grid' according to their agreement with them. Factor analysis was then used to identify common patterns in respondents' card sorts and to present respondents' accounts. We present the factors that emerge from this analysis and then design survey methods to explore the extent to which these views exist in a representative sample of the UK population. These methods will be adapted and applied in a large European study (EuroVaQ).

“What is peculiar about the duck-billed platypus? It has a duck-type bill, a furry body like a mole, it lays eggs, and it suckles its young! Now the type of analysis you have employed would run as follows... many birds have duck-type bills, and lots of animals have furry bodies, and as for laying eggs, this is common among birds and reptiles, and all mammals suckle their young, therefore the duck-billed platypus „would appear to have no characteristics which differentiate it sharply from other...‟ etc. I hope my point is clear.”

Publicly funded healthcare systems operating with fixed budgets must incorporate rationing mechanisms of some sort in order to set priorities. Efficiency, which might be defined broadly in health terms as maximising health benefits with respect to cost, is a key consideration in setting priorities. However, efficiency is not the only consideration, and members of society may value other issues in relation to the distribution of resources to different groups of beneficiaries. Life-extending treatments for people with terminal illnesses, which are non-curative by definition and often produce relatively small health gains in relation to their costs, are a prime example of technologies that might not satisfy usual cost-effectiveness thresholds. It is generally accepted that the views and values of members of the public, as taxpayers and potential patients, are relevant in determining priorities in the provision of publicly funded healthcare. This chapter introduces Q methodology as a structured approach to eliciting and describing societal values, combining qualitative and quantitative techniques to study subjectivity, with reference to research carried out relating to people at the end of their lives.

Abstract
Background: Many publicly-funded health systems apply cost-benefit frameworks in response to the moral dilemma
of how best to allocate scarce healthcare resources. However, implementation of recommendations based on costs
and benefit calculations and subsequent challenges have led to ‘special cases’ with certain types of health benefits
considered more valuable than others. Recent debate and research has focused on the relative value of life extensions
for people with terminal illnesses. This research investigates societal perspectives in relation to this issue, in the UK.
Methods: Q methodology was used to elicit societal perspectives from a purposively selected sample of data-rich
respondents. Participants ranked 49 statements of opinion (developed for this study), onto a grid, according to
level of agreement. These ‘Q sorts’ were followed by brief interviews. Factor analysis was used to identify shared
points of view (patterns of similarity between individuals’ Q sorts).
Results: Analysis produced a three factor solution. These rich, shared accounts can be broadly summarised as:
i) ‘A population perspective – value for money, no special cases’, ii) ‘Life is precious – valuing life-extension and
patient choice’, iii) ‘Valuing wider benefits and opportunity cost - the quality of life and death’.
From the factor descriptions it is clear that the main philosophical positions that have long dominated debates
on the just allocation of resources have a basis in public opinion.
Conclusions: The existence of certain moral positions in the views of society does not ethically imply, and
pragmatically cannot mean, that all are translated into policy. Our findings highlight normative tensions and
the importance of critically engaging with these normative issues (in addition to the current focus on a
procedural justice approach to health policy). Future research should focus on i) the extent to which these
perspectives are supported in society, ii) how respondents' perspectives relate to specific resource allocation
questions, and iii) the characteristics of respondents associated with each perspective.

Keywords: Social values, Life extension, Terminal illness, Societal perspectives, Health policy, Ethics, Resource
allocation, Q methodology

Preference elicitation studies reporting societal views on the relative value of end-of-life treatments have produced equivocal results. This paper presents an alternative method, combining Q methodology and survey techniques (Q2S) to determine the distribution of 3 viewpoints on the relative value of end-of-life treatments identified in a previous, published, phase of this work. These were Viewpoint 1, "A population perspective: value for money, no special cases"; Viewpoint 2, "Life is precious: valuing life-extension and patient choice"; and Viewpoint 3, "Valuing wider benefits and opportunity cost: the quality of life and death." A Q2S survey of 4,902 respondents across the United Kingdom measured agreement with these viewpoints; 37% most agreed with Viewpoint 1, 49% with Viewpoint 2, and 9% with Viewpoint 3. Regression analysis showed associations of viewpoints with gender, level of education, religion, voting preferences, and satisfaction with the ...

Criteria used by the National Institute for Health and Care Excellence (NICE) to assess life-extending, end-of-life (EoL) treatments imply that health gains from such treatments are valued more than other health gains. Despite claims that the policy is supported by societal values, evidence from preference elicitation studies is mixed and in-depth research has shown there are different societal viewpoints. Few studies elicit preferences for policies directly or combine different approaches to understand preferences. Survey questions were designed to investigate support for NICE EoL guidance at national and regional levels. These 'Decision Rule' and 'Treatment Choice' questions were administered to an online sample of 1496 UK respondents in May 2014. The same respondents answered questions designed to elicit their agreement with three viewpoints (previously identified and described) in relation to provision of EoL treatments for terminally ill patients. We report the ...

Resources available to the health care sector are finite and typically insufficient to fulfil all the demands for health care in the population. Decisions must be made about which treatments to provide. Relatively little is known about the views of the general public regarding the principles that should guide such decisions. We present the findings of a Q methodology study designed to elicit the shared views in the general public across ten countries regarding the appropriate principles for prioritising health care resources. In 2010, 294 respondents rank ordered a set of cards and the results of these were subject to by-person factor analysis to identify common patterns in sorting. Five distinct viewpoints were identified, (I) "Egalitarianism, entitlement and equality of access"; (II) "Severity and the magnitude of health gains"; (III) "Fair innings, young people and maximising health benefits"; (IV) "The intrinsic value of life and healthy living"; (V) "Quality of life is more important than simply staying alive". Given the plurality of views on the principles for health care priority setting, no single equity principle can be used to underpin health care priority setting. Hence, the process of decision making becomes more important, in which, arguably, these multiple perspectives in society should be somehow reflected.

To identify shared patterns of views in young people relating to the influence of industry-driven alcohol marketing (price, promotion, product and place of purchase/consumption) on their reported drinking behaviour. Q methodology harnessed qualitative and quantitative data to generate distinct clusters of opinions as follows: 39 opinion statements were derived from earlier in-depth qualitative interviews with 31 young people; by-person factor analysis was carried out on 28 participants' (six previous interviewees and 22 new recruits) rank orderings of these statements (most-to-least agreement); interpretation of the factor arrays was aided by 10-15-minute debriefing interviews held immediately following each Q-sort. Northeast England Young people aged 14-17 years purposively recruited from high schools, higher education colleges, youth centres and youth offending teams. Centroid factor extraction and varimax rotation of factors generated three distinct accounts: factor one (&#39...

This paper reports the results of the follow-up, face-validity test on a protocol developed to explore the impact of context and baseline risk on peoples? marginal rates of substitution between wealth and risk of death across a range of contexts using a modified risk-risk trade-off methodology. Analysis of these qualitative interviews revealed that context had different effects for different people.