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Education for Health, Vol. 14, No. 1, 2001, 109 117

PRACTICAL ADVICE

Editors note: This is the fourth and last in a special series of articles prepared by
these authors for our journal. We solicited this series with the intention of
expanding the awareness, appreciation, and expertise of our readers in the
important, but still minimally used, strategy of qualitative research. We welcome
papers based on the appropriate use of this strategy.

Getting Qualitative Research Published

KELLY J. DEVERS, PhD1 & RICHARD M. FRANKEL, PhD2
1

Health Researcher, Center for Studying Health System Change, USA;

and 2 Professor of Medicine and Community and Preventive Medicine,
University of Rochester, School of Medicine and Dentistry, USA

ABSTRACT Translating research findings in health education into a publishable

manuscript is challenging regardless of whether qualitative or quantitative methods are
used. In this paper, we offer practical advice about how to successfully prepare and guide
manuscripts based on qualitative research methods, in particular through the peerreviewed journal publication process. Researchers trying to publish qualitative findings
may face some unique challenges, given the fields current knowledge of qualitative
methods, evaluation criteria, and conventional manuscript styles and length.
KEYWORDS Qualitative research, methodsqualitative, dissemination, publication.

Introduction
Despite its critics (e.g. Poses & Isen, 1998), qualitative research (QR) in health
care and health profession education is being published in the mainstream
literature with increasing frequency. Some journals, such as the British Medical
Journal and Health Services Research (Devers et al., 1999), have devoted entire
special issues or supplements to the topic. Other journals, such as the Journal of

Author for correspondence: Kelly J. Devers, PhD, Health Researcher, Center for Studying Health
System Change, 600 Maryland Avenue SW, Suite 500, Washington, DC 20024-2512 , USA. Tel: +1
(202) 484-5261. E-mail: [email protected] m
Education for Health ISSN 13576283 print/ISSN 14695804/online
http://www.tandf.co.uk/journals
DOI: 10.1080 /1357628001002188 8

2001 Taylor & Francis Ltd

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the American Medical Association (Giacomini & Cook, 2000a,b), have recently
devoted multiple articles to evaluating the evidence from QR studies.
Qualitative research has a long and venerable intellectual history in such
social science disciplines as anthropology, sociology, psychology and linguistics,
with numerous how to texts that describe general research principles and
applications. Recently, comprehensive texts in QR that focus on specific
clinical settings such as primary care medicine (Crabtree & Miller, 1992, 1999),
and nursing (Morse, 1991) have appeared. They provide helpful advice on
manuscript preparation for publication in the health professions literature.
Such resources are particularly helpful because they are targeted to the specific
needs and questions of researchers in these settings. They are welcome
additions to a family of methods whose value in health care continues to grow,
becoming better known and understood.
In this paper we focus on the publication process. In many ways, successful
publication of QR is no different from publishing quantitative research. A
clearly written manuscript, describing both the methods and results, based on
having asked an important question, are essential components of all research
reports. QR, however, does have some unique characteristics and standards of
evidence that differ from quantitative research. Several treatments of the
qualities of QR have appeared recently and are recommended (Devers, 1999;
Frankel, 1999; Inui & Frankel, 1991).

The Review Process

In a peer-reviewed journal, which we consider to be the standard of academic
practice, the first step an editor or associate editor generally takes in deciding
about a submissions eligibility for publication is determining the manuscripts
fit with the journals mission and areas of focus. If found appropriate, the
manuscript will typically be sent to two or more peer reviewers for their critical
comments and recommendations regarding publication. Some journals ask
reviewers for two sets of comments: one for the authors and one for the editor.
These can vary quite considerably. It can happen, for example, that generally
positive comments are sent for the author, although the comments to the editor
recommend rejection. This can happen when one or more reviewers feel that
the paper has a significant or fatal flaw, which they dont mention in their
comments to the author. Many editors attempt to synthesize aspects of the
reviewers comments to the editor with their comments to the author in their
letter to the author.
For each manuscript, reviewers are typically asked to recommend whether
to accept as is, accept with minor modifications, reconsider after major
modifications, or reject. Usually, accept as is is the only condition carrying a
commitment to publish. Other responses (except reject) imply an interest in

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publishing but not a commitment. Seasoned authors (both qualitative and

quantitative) have stories about protracted exchanges with journal editors who
kept wanting further changes after several revisions were submitted.
There are a number of other steps between acceptance and publication,
generally involving editing for clarity and brevity, preparing/revising graphs
and tables, and improving the cited references. We wont deal with those issues
here. We address issues in the research, writing, review and editing processes
that can optimize the chances of getting qualitative research published.

Being Clear about the Research Question and Audience

Central to all good research studies is a clearly asked question with welldescribed methods and results. Your research question(s) must be appropriate
for your field and relevant for those you hope will read your report. As early in
the research process as possible you should become familiar with the readership
and editorial policies of the likely journals for your submission. Although it
may seem only dimly relevant at the outset of a QR project, giving some early
thought as to who the ultimate readers of your report are likely to be will be
quite important. Is the study designed to increase awareness of a phenomenon
(say, low self-esteem affecting learners grades) or to provide feedback to
improve performance (e.g. studying the effect of professional development on
improving end-of-life care)? Most editors act as filters for their readers. For
many, their first question is, How will this study add to the stock of knowledge
that our readers seek to get from our journal? Authors hoping to publish QR
should familiarize themselves with the range of journals that publish such work,
the audience(s) they target and their editorial policies. Reading one or several
issues of your candidate journals will provide you with a flavor for the types of
studies and research traditions supported by those journals. It may also pay to
search the literature for articles that deal directly with the question of QR
publication. If you are considering publishing in the area of health services
research and management, a useful resource is a recent article by Hoff and Witt
(2000) showing the rates of QR publication in a range of such journals. They
found that about one in seven published research articles used qualitative
methods and that two of the nine journals reviewed contributed 45% of the
total number of articles using qualitative methods. Targeting journals that more
frequently publish qualitative research is a good place to start. In the area of
educational research, virtually all health professions education journals are now
open to qualitative research.
Published papers dont reveal their prepublication history: the number of
journals that may have rejected it previously or the number of rewrites it may
have gone through prior to publication. A useful strategy, although by no
means ensuring acceptance for publication, is contacting an author whose
published work is similar to yours, to ask about her/his experience up to and
including publication of the finished product. Using this strategy early can
reduce the possibility of a mismatch among author(s), reviewer(s) and editor(s)

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and can also provide something of a guide to the publication process. Knowing
that a particular type of QR study was reviewed and accepted for publication
on the first try, while another required five journal submissions and an equal
number of rewrites, can help you set realistic expectations.

Describing Research Tradition and Methods

As we pointed out in the first article in this series (Frankel & Devers, 2000),
QR is a family of methods and traditions. When preparing an article for
publication it is important to inform the reader (and the reviewer) which
tradition or combination of traditions your study utilizes. Reviewers, in
particular, may be put off by the use of a generic phrase like qualitative
research approach to describe methods that might more appropriately be
labeled ethnographic, or participant observation. Several good roadmaps to
QR traditions are available (Crabtree & Miller, 1992, 1999; Cresswell, 1998).
When presenting QR, in addition to describing the tradition from which
your research derives, you should ensure its trustworthiness by explaining the
steps you took in securing your evidence. Reviewers who were schooled in one
or more of the QR research traditions look for evidence that the researcher is
familiar with the methods, cannons of evidence and checks and balances for the
material being analyzed. A description of methods that reads, for example,
Focus group analysis was used to identify various themes related to student
perceptions of the educational programs impact on their self-esteem is
unlikely to be acceptable to a reviewer simply because it contains too little
information about how the themes were identified and analyzed by the authors.
A more useful statement would be, Focus group conversations were (audio/
video) recorded and transcribed. Two investigators, working independently,
reviewed the transcripts using a highlighter to identify portions of text that
appeared to describe a theme. Each highlighted section was labeled as a theme,
and the results were then compared to discover areas of agreement and
disagreement. Attempts were then made to reconcile disagreements though a
process of iterative or repetitive consensus building. Such a description
provides a sketch for the reviewer and ultimately the reader to follow in
understanding the research process.
Preparing a Manuscript
We consider four aspects of QR manuscript preparation especially important:
audience, language, length, and peer review.
Audience. As already mentioned, those for whom the paper is prepared are
important in determining a QR papers likelihood of getting published. In many
respects the question of audience boils down to a matter of emphasis and degree.
One of us, RMF, recently participated in a QR study of how physicians handle
awkward movements when doing HIV assessments. That project was intended
for publication in the Annals of Internal Medicine (Epstein et al., 1998). Since

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that is a journal whose readership is composed largely of practicing physicians

the study team decided to focus more on the results of the analysis and their
implications for practice than on the fine details of the methods. A discussion of
the details might have been of interest and relevance to methodologists but of
limited use and interest to our intended audience, practicing physicians.
Language. This is perhaps the most important and most neglected aspect of
publishing QR. The language you use to describe research findings should align
with the language standards of the target audience. The anthropologist Horace
Miner, in a paper entitled Body ritual among the Nacirema (1956), made this
point elegantly almost half a century ago. Miner describes the curious customs
and habits of the Nacirema with descriptions such as the following: They [the
Nacirema] are a North American group living in the territory between the
Canadian Cree, the Yaqui and Tanahumare of Mexico, and the Carib and
Arawak of the Autilles... According to Nacirema mythology their nation was
originated by a culture hero, Notgnihsaw... The most powerful [people] are the
medicine men... who have an imposing temple, or latipso in every community of
any size.
Miners language in describing this culture is deliberately obfuscating. In
fact, it is a description of American culture. Nacirema is American spelled
backwards! So, too, is the description of the culture hero, Notgnihsaw
(Washington), and the imposing temple, latipso ([h]ospital). In the context
of teaching about the importance of language when describing events, persons
and research results, approximately 75% of students who read and were asked
to analyze the culture described by Miner do not recognize that it is a
description of their own culture. Obviously, language counts.
In many types of qualitative research, the specific language of those studied
is also very important because it is the data from which conclusions are drawn.
This raises the question of how to use quotes effectively in a manuscript,
particularly given journal style conventions and potential space constraints.
Quotes are best used to illustrate key points of the paper and to demonstrate
careful management and analysis of transcripts and other types of qualitative
data. For example, using quotes from medical students that illustrate how they
feel about persons with HIV can be far more powerful than the authors
description of those feelings. As has been frequently observed, some health
professionals reveal their discomfort with some patients and conditions with the
pejorative terms and humor they use when talking about them (as repeatedly
illustrated in Shems 1981 autobiographical novel).
Length. A significant challenge for QR publication is the restriction on length
imposed by many mainstream health professions journals. Although length
restrictions can be a challenge when publishing any type of research, it is
especially so for QR, where large blocks of text illustrating themes or
experiences are necessary and desirable. Some journals are making needed

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adaptations. As noted by Giacomini and Cook (2000b), in their recent review of

qualitative research in health care, Because of the importance of detail in
qualitative reports, some health research journals allow substantially longer page
limits for qualitative studies.
We have two suggestions for addressing the issue of length when submitting
QR for publication. First, draw explicit attention to the issue of paper length
(word count) in your letter of submission to the journal. If you need to educate
an editor about the requirement for additional space, it is better to try doing so
at the beginning, rather than at the end, of the review process. Second, consider
making longer segments of text or entire transcripts available via the Internet.1
Additionally, you can consider making streaming audio or video data samples
available via the Internet to qualified researchers, while following human
subjects protection protocols. This approach is growing in popularity as
electronic media supported by the Internet become more widely disseminated
throughout the world.
Pre-submission Reviews. A useful strategy for clarifying and sharpening QR is
having colleagues read and comment on early manuscript drafts. Sending drafts
to experienced researchers in a particular area, e.g. phenomenological studies,
can be useful in some situations. Friendly reviews can reveal significant flaws in
logic and description that could lead to rejection if the paper were under actual
review.

Manuscript Submission
Peer-reviewed journals vary widely in the amount of time they take from
submission to publication. If you are in doubt or in a hurry, an accepted
procedure is sending a copy of the manuscript to the editor requesting a
judgment on the appropriateness of the paper for that journal. Editors are
generally willing to accommodate such requests in one to three weeks. Note: a
positive reply doesnt ensure acceptance, only that you have found a journal
that will put your paper through the review process.
Another useful strategy when submitting QR papers is including a list of
suggested reviewers in the cover letter to the editor. Because QR is relatively
new to many health professions journals, editors often appreciate the inclusion
of a list suggesting four to six well-qualified reviewers. Limit your
recommendation to reviewers who you believe will give yours and other
qualitative researchers papers a fair and balanced reading.
Finally, once a manuscript has been submitted and accepted for review, it
may be useful to track its progress. Manuscript review is generally done on a
volunteer basis by colleagues who, like authors, are also very busy. Dont
assume that no news is good or bad. Assume rather that for one reason or
another the editor has not received the reviews back in a timely way.
Occasional, gentle prodding is unlikely to harm your chances of getting your
manuscript published and it may help speed up the review process.

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What to Do If Your Manuscript Is Rejected

No one enjoys having a paper rejected, whether it is QR or not. When faced
with a rejection, consider these options.
If you had your heart set on publishing in the journal that rejected your
paper, you can ask for a re-review. Such requests should be accompanied by a
carefully stated rationale: e.g. your suspicion that the reviewer(s) in question
were not sufficiently knowledgeable about QR, the review was cursory and
lacked substance or detail (if true), you disagree about the importance of the
questions, method or theory proposed by the reviewer(s).
If you decide to submit to another journal, use the reviewers critique(s) to
guide your revision of your paper. Many authors have a list of journals
prioritized from most to least important and influential for the study in
question. A rejection from one journal is replaced by submission to the next
journal on the list.
Provisional Acceptance
As weve pointed out, provisional acceptance of any type of paper is not a
commitment to publish. It is rather a statement of probability, high in the case
of minor revisions and far less for major rewrites. Minor revisions should be
done on a point-by-point basis, incorporating the reviewers feedback, if helpful
and relevant. Typically, a reviewers call for minor revisions is not the place for
major disagreements. It is like negotiating one or several details of an otherwise
agreed-to contract.
More challenging is the situation where a reviewer has asked for major
revisions in methods, data analysis, discussion or conclusions. In considering
major revisions it is important to weigh the amount of time and effort the
revisions will take against the time it will take for the paper to be reviewed for
another journal. Occasionally, a reviewer will call for major revisions that the
author fundamentally disagrees with, e.g. saying a participant observation
framework should have been used instead of focus groups to study students
experiences in a rural community. It is possible to appeal such disagreements in
a letter to the editor carefully laying out the rationale for the methods used.
Since the category of major revisions represents virtually no commitment to
publish on the journals part, this might be considered a high risk/high gain
situation. As with any type of rewrite the paper should go through a presubmission, friendly review process.
Resources
As QR has continued to garner interest in health-related fields a number of
resources that are directly and indirectly helpful in getting studies published
have become available. For example, the national meetings of both the Society
of General Internal Medicine (SGIM) and the Society of Teachers of Family
Medicine (STFM) in the US offer workshops and symposia on QR, including
offerings on how to publish QR results. In addition, the North American

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Primary Care Research Group (NAPCRG) actively supports QR activities.

The US Agency for Healthcare Research and Quality (AHRQ), formerly
known as the Agency for Health Care Policy and Research, sponsors a yearly
conference on methods of research in health care, including a focus on both
qualitative and multi-method research. Additional extended courses and
opportunities to learn about and publish QR are available via the International
Institute for Qualitative Research at the University of Alberta, Canada
http://www.ualberta.ca/~iiqm/ . In addition, Nova University maintains a
list of websites that feature QR at:
http://www.nova.edu/ssss/QR/
qualres.html . Undoubtedly, research and education societies in the health
professions in many other countries now offer support for members interested
in QR.

Conclusion
We hope it is now clear that publishing QR demands many of the same
strategies as publishing other forms of research. Core requirements are clear,
concise writing, precise articulation of methods, and relevance of results, all
presented in a way that fits the expectations of the reading audience.
Publishing QR presents some unique challenges as well. Space limitations,
research traditions and variations in the quality and qualifications of reviewers
can all be barriers to publication. Understanding the process a paper goes
through in the review and editorial process can help minimize such barriers and
make the process of moving from research in the field to publication of results
more rational and satisfying in the short and long run.

Note
1. In July 2001, our journal will publish a supplement to our regular issue,
composed of the theme papers from the annual meeting of Community
Campus Partnerships for Health. Each of the original papers substantially
exceeds our journals page limits. The authors are redoing their papers to
conform to our limits and will be posting their original papers and many
valuable, accompanying resources on their organizations website.

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